Randomized Controlled Trial of Combined Letrozole and Clomid (CLC II) Versus Letrozole Alone for Women With Anovulation
Phase: PHASE4
Conditions: Polycystic Ovary Syndrome, PCOS, Infertility
Sponsor: Rachel Mejia

CLC II Protocol Manual 
Protocol Version 1.2 
IRB# 201906826 
9-27-2021 
 ________________________________________________________________________________________________________  
 
 ____________________________________________________________________________________________ 
 
 
Title: Randomized controlled trial of Combined 
Letrozole and Clomid (CLC II) versus Letrozole 
alone for women with anovulation 
Principal Investigator: Rachel Mejia, DO 
Draft or Version Number:  1.3 
 
 
 
 
 
September 21, 2021 
This document is confidential. 
No part of it may be transmitted, reproduced, published, or used by other persons 
without prior authorization from the Sponsor or Principal Investigator. 
 
 
Protocol Version History 
Protocol 
Version 
Version 
Date 
Brief description of protocol modification/actions 
requested, if any 
1.0 
11/16/2020 
 
1.1 
7/27/2021 
Addition of GAD-7, PHQ-9, FertiQoL, and Perceived Stress 
Scale Questionnaires. Specification of BMI cut-off. Addition of 
UI Jordan Creek site. 
1.2 
9/21/2021 
Addition of UW site specific information. 
1.3 
8/2/2023 
Clarification of eligibility criteria, provision of direction for 
additional potential results at midluteal visit, grammatical 
edits 
 
 
 
 
 
 
 
 
 
 
 
 
 

CLC II Protocol Manual 
Protocol Version 1.2 
IRB# 201906826 
9-27-2021 
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Based on NIDCR Clinical Trial (Interventional) Protocol Template v4.0 - 20140103 
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STATEMENT OF COMPLIANCE 
The study will be conducted in accordance with the International Conference on 
Harmonisation guidelines for Good Clinical Practice (ICH E6), the Code of Federal 
Regulations on the Protection of Human Subjects (45 CFR Part 46), and local IRB 
regulations. All personnel involved in the conduct of this study have completed human 
subjects protection training. 

CLC II Protocol Manual 
Protocol Version 1.2 
IRB# 201906826 
9-27-2021 
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Based on NIDCR Clinical Trial (Interventional) Protocol Template v4.0 - 20140103 
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SIGNATURE PAGE 
The signature below constitutes the approval of this protocol and the attachments, and 
provides the necessary assurances that this trial will be conducted according to all 
stipulations of the protocol, including all statements regarding confidentiality, and 
according to local legal and regulatory requirements and applicable US federal 
regulations and ICH guidelines. 
Principal Investigator or Clinical Site Investigator: 
Signed: 
 
Date:  
 
Name:  
 
Title:  
 
Signed: 
 
Date:  
 
Name:  
 
Title:  
Signed: 
 
Date:  
 
Name:  
 
Title:  
Signed: 
 
Date:  
 
Name:  
 
Title:  
 
 
 

CLC II Protocol Manual 
Protocol Version 1.2 
IRB# 201906826 
9-27-2021 
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Based on NIDCR Clinical Trial (Interventional) Protocol Template v4.0 - 20140103 
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TABLE OF CONTENTS 
[This table uses the Table of Contents function in Microsoft Word that will automatically update headings and page 
numbers used in the body of the report.  To update the Table of Contents and all cross-references in the document, 
press CTRL-A to select the entire document, then press F9.] 
PAGE 
STATEMENT OF COMPLIANCE ................................................................................................. I 
SIGNATURE PAGE .................................................................................................................... II 
TABLE OF CONTENTS ............................................................................................................. III 
LIST OF ABBREVIATIONS ....................................................................................................... VI 
PROTOCOL SUMMARY .......................................................................................................... VII 
1 
KEY ROLES AND CONTACT INFORMATION ................................................................. 11 
2 
INTRODUCTION: BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE ....... 12 
2.1 
Background Information ........................................................................................ 12 
2.2 
Potential Risks and Benefits ................................................................................. 14 
2.2.1 
Potential Risks .......................................................................................... 14 
* Table is modified from PPCOS II trial ................................................................. 15 
2.2.2 
Potential Benefits ...................................................................................... 15 
3 
OBJECTIVES ................................................................................................................... 17 
3.1 
Primary Research Hypothesis ............................................................................... 17 
3.1.1 
Primary Outcome Measure ........................................................................ 17 
3.2 
Secondary Research Hypothesis and outcome measures .................................... 17 
4 
STUDY DESIGN .............................................................................................................. 19 
4.1 
Treatment Design ................................................................................................. 19 
4.1.1 
Rationale for dosing approach ................................................................... 20 
4.2 
Study Summary .................................................................................................... 20 
5 
STUDY ENROLLMENT AND WITHDRAWAL .................................................................. 23 
5.1 
Study Population ................................................................................................... 23 
5.2 
Subject Inclusion Criteria ...................................................................................... 24 
5.3 
Subject Exclusion Criteria ..................................................................................... 24 
5.4 
Strategies for Recruitment and Retention ............................................................. 25 
5.5 
Treatment Assignment Procedures ....................................................................... 27 
5.5.1 
Randomization Procedures ....................................................................... 27 
5.6 
Subject Withdrawal ............................................................................................... 28 
5.6.1 
Reasons for Withdrawal ............................................................................ 28 
6 
STUDY INTERVENTION .................................................................................................. 29 
6.1 
Study Product Description .................................................................................... 29 
6.1.1 
Formulation, Packaging, and Labeling....................................................... 29 
6.1.2 
Product Storage and Stability .................................................................... 30 
6.2 
Administration of Study Product ............................................................................ 30 
6.3 
Accountability Procedures for the Study Product .................................................. 31 
6.4 
Assessment of Participant Compliance with Study Product Administration ........... 31 
7 
STUDY SCHEDULE ......................................................................................................... 32 
7.1 
Screening ............................................................................................................. 32 
7.2 
Enrollment/Baseline .............................................................................................. 33 

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7.3 
Intermediate Visits ................................................................................................ 34 
7.4 
Pregnancy Track Visits (part of routine care obstetrical care) ............................... 40 
7.5 
Final Study Visit/Cycle 3 Menses check in ............................................................ 42 
8 
STUDY PROCEDURES /EVALUATIONS ........................................................................ 44 
8.1 
Study Procedures/Evaluations .............................................................................. 44 
8.2 
Medical record review will be performed for labs, including: TSH, prolactin, 
HbgA1c, 17-OH Progesterone, AMH, Rubella, FSH and estradiol, Total 
testosterone and SHBG; progesterone documenting anovulation. All of these 
labs are not required for participation but if they have been done should be 
documented.  Documentation of TSH, HbgA1c and Rubella status 
recommended for participation.  These will be entered into RedCap. .................... 44 
8.2.1 
Clinical Laboratory Evaluations performed at local labs ............................. 44 
9 
ASSESSMENT OF SAFETY ............................................................................................ 46 
9.1 
Specification of Safety Parameters ....................................................................... 46 
9.1.1 
Adverse Events ......................................................................................... 46 
9.1.2 
Serious Adverse Events ............................................................................ 46 
9.2 
Time Period and Frequency for Event Assessment and Follow-Up ....................... 46 
9.3 
Characteristics of an Adverse Event ..................................................................... 46 
9.3.1 
Relationship to Study Intervention ............................................................. 47 
9.3.2 
Expectedness of SAEs .............................................................................. 47 
9.3.3 
Severity of Event ....................................................................................... 47 
9.4 
Reporting Procedures ........................................................................................... 47 
10 
STUDY OVERSIGHT ....................................................................................................... 49 
11 
CLINICAL SITE MONITORING ........................................................................................ 50 
12 
STATISTICAL CONSIDERATIONS/DATA ANALYSIS ..................................................... 51 
12.1 
Justification of Effect Size ..................................................................................... 51 
12.1.1 Prior Studies.............................................................................................. 51 
12.1.2 Minimum Clinically important differences ................................................... 51 
12.1.3 Significance Testing .................................................................................. 51 
12.1.4 Sample Size Calculations .......................................................................... 52 
12.2 
Statistical Analysis ................................................................................................ 52 
12.3 
Secondary Analyses ............................................................................................. 52 
12.3.1 Descriptive Summary ................................................................................ 52 
12.3.2 Statistical Analyses ................................................................................... 52 
12.3.3 Other Secondary Analyses ........................................................................ 52 
12.3.4 Sub study Analyses ................................................................................... 53 
12.3.5 Sample size calculation ............................................................................. 54 
12.4 
Missing Data ......................................................................................................... 54 
12.5 
Adverse Event Analysis ........................................................................................ 54 
12.6 
Interim Analysis .................................................................................................... 54 
13 
ETHICS/PROTECTION OF HUMAN SUBJECTS ............................................................. 55 
13.1 
Ethical Standard ................................................................................................... 55 
13.2 
Institutional Review Board .................................................................................... 55 
13.3 
Informed Consent Process ................................................................................... 55 

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13.4 
Subject Confidentiality .......................................................................................... 55 
14 
DATA HANDLING AND RECORD KEEPING ................................................................... 58 
15 
PUBLICATION/DATA SHARING POLICY ........................................................................ 59 
16 
LITERATURE REFERENCES .......................................................................................... 60 
APPENDICES ........................................................................................................................... 62 
APPENDIX A: SCHEDULE OF EVENTS .................................................................................. 63 
 

CLC II Protocol Manual 
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LIST OF ABBREVIATIONS 
AE 
Adverse Event/Adverse Experience 
AMH 
Anti-Müllerian Hormone 
BMI 
Body Mass Index 
CD 
Cycle Day 
CFR 
Code of Federal Regulations 
CONSORT 
Consolidated Standards of Reporting Trials 
CRF 
Case Report Form 
DHEAS 
Dehydroepiandrosterone Sulfate 
FDA 
Food and Drug Administration 
FSH 
Follicle Stimulating Hormone 
GCP 
Good Clinical Practice 
HbgA1c 
Hemoglobin A1C 
hCG 
Human Chorionic Gonadotropin 
HIPAA 
Health Insurance Portability and Accountability Act 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
IRB 
Institutional Review Board 
IUP 
Intrauterine Pregnancy 
LH 
Luteinizing Hormone 
MedDRA 
Medical Dictionary for Regulatory Activities 
MOP 
Manual of Procedures 
N 
Number (typically refers to subjects) 
NIH 
National Institutes of Health 
P4 
Progesterone 
PPCOS II 
Pregnancy in Polycystic Ovary Syndrome Study II 
PI 
Principal Investigator 
QA 
Quality Assurance 
QC 
Quality Control 
REDCap 
Research Electric Data Capture 
SAE 
Serious Adverse Event/Serious Adverse Experience 
SHBG 
Sex Hormone Binding Globulin 
TSH 
Thyroid Stimulating Hormone 
UIHC 
University of Iowa Hospitals and Clinics 
WHO 
World Health Organization 

CLC II Protocol Manual 
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PROTOCOL SUMMARY 
Title: 
Randomized controlled trial of Combined Letrozole and Clomiphene 
(CLC II) versus letrozole alone for women with anovulation 
Précis: 
This is a multi-center, randomized controlled open-label clinical 
trial of letrozole alone versus combination of letrozole and 
clomiphene citrate (CC) for up to 3 treatment cycles.  Letrozole 
dosing will be increased in a stair-step fashion based on 
ovulation results.  Participants will return for a mid-luteal 
ultrasound and progesterone lab to determine ovulatory status. 
Women will be randomized in a 1:1 ratio and the randomization 
scheme will be coordinated through the UIHC. Randomization 
will be stratified by site, age and BMI.  The primary analysis will 
use an intent-to-treat approach to evaluate ovulatory rate in the 
two treatment arms.  
Objectives: 
 
To determine efficacy and safety of the combination letrozole 
and CC compared to letrozole alone in achieving ovulation in 
infertile women with anovulation.  
 
Primary Outcome:  Ovulation will be the primary outcome 
determined by a mid-luteal progesterone level > 3 and 
cumulative ovulation rate will be the primary efficacy parameter. 
 
Secondary Outcome:  Secondary efficacy parameters will 
include pregnancy rate (conception and clinical pregnancy), live 
birth rate, multiple gestation live birth rate, pregnancy loss rate 
(biochemical, miscarriage, ectopic) and time to pregnancy.  
Side effect profile and complication rate will be monitored and 
reported. 
Obstetric outcomes will include pregnancy complication rate, 
birth weight and sex, neonatal complication rate.   
Ultrasound findings will be reported and compared between the 
two groups including: number of corpora lutea and endometrial 
thickness.  
ClinicalTrials.gov 
Identifier 
201906826 
Population: 
184 healthy women infertile women with polycystic ovary 
syndrome or normogonadotropic normoestrogenic anovulation 
or oligo-ovulation, age > 18 to <40. Additionally, the couple will 
have no other major infertility factor.  
Phase: 
IV 
Number of Sites: 
4 sites 

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University of Iowa Hospitals and Clinics Iowa City, IA with 2 
ancillary sites 
- 
Quad Cities Clinic, Davenport, IA 
- 
Jordan Creek Clinic, Des Moines, IA 
University of Wisconsin, Generations Clinic, Middleton, WI 
 
Description 
of  
Intervention: 
184 women will be equally randomized to two different treatment 
arms at time of menses (spontaneous or induced with progestin 
withdrawal) or random start: A) letrozole 2.5 mg every day for 5 
days (days 3-7 of cycle), or B) letrozole 2.5 mg and clomiphene 
citrate 50 mg every day for 5 days (days 3-7 of cycle), for a total 
of up to 3 treatment cycles.  
Letrozole dose will be increased in subsequent cycles in both 
groups based on ovulatory response in stairstep fashion (details 
within protocol).   Maximum letrozole dose will be 7.5 mg a day 
for 5 days.   
 
Study Duration: 
2 years 
Subject 
Participation 
Duration: 
Approximately 15 weeks of active participation time.  Clinical 
chart abstraction and remote follow up will be continued until 6-
8 weeks post-delivery in pregnant women.   
Estimated Time to 
Complete 
Enrollment: 
20 months with 3 months follow up for final enrollees. 21 months 
by enrolling ~ 10 women per month across the 4 sites.   

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Schematic of Study Design: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Revised from PPCOS II Trial protocol study diagram 
 
Detailed Schematic of Study Design: 
Consent and screen  
Screen out 
Randomize 
(N=184) 
Continue at response 
dose until nonresponse, 
pregnancy or 3 cycles 
No-ovulation 
Primary Outcome 
Arm 1: Letrozole  
N = 92 participants 
Arm 2: Letrozole + 
Clomiphene 50 mg 
N = 92 participants 
ovulation 
Increase Letrozole treatment 
dose by 2.5 mg/day up to 
maximum dose of 7.5mg/day x 5 
days until response or 3 cycles 
Secondary outcomes: ultrasound 
dynamics, pregnancy, live birth, multiple 
gestation, side effects  

CLC II Protocol Manual 
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Screening 
Visit 
 
 
 
Baseline  
Visit 
(Cycle day 1-3, random start) 
 
 
 
 
 
 
 
 
Cycle day  
3-7 
 
 
Midluteal visit 
Cylce day 18- 26 
 
 
 
 
 
 
 
 
 
 
 
 
 
Menses check in 
Menses onset 
 
 
Total:184 Confirm negative pregnancy test, dispense meds, dispense and review 
journal log 
Randomize 
Obtain informed consent. Screen potential participants by inclusion and exclusion 
criteria; obtain history, physical exam. Pre-conception counseling. Progestin 
withdraw if indicated. 
Participants to take Letrozole 2.5 + 1 pill study medication daily cycle days 3-5, 
Participants to complete journal log and other assigned questionnaires  
Progesterone ≥ 3ng/mL 
Participant awaits 
menses and pregnancy 
test at 2 wks) 
Arm 2:92 Letrozole + 50mg 
CC 
Arm 1:92 Letrozole  
participants 
Perform midluteal assessments (transvaginal ultrasound, progesterone lab draw, 
review journal log).  
Progesterone < 3ng/mL 
& follicular development 
Repeat progesterone in 
10-14 days 
Progesterone < 3ng/mL 
& no follicular 
development. Increase 
Letrozole dose by 
2.5mg/day up to 
maximum dose of 
7.5mg/day starting that 
day 
Repeat 
cycles at 
adjusted 
letrozole 
dosing as 
needed 
up to 3 
cycles  
Progesterone ≥ 3ng/mL 
Increase Letrozole dose by 
2.5mg/day up to maximum dose of 
7.5mg/day starting with next 
menses) 
No menses: within two 
weeks – urine 
pregnancy test 
Menses onset. Confirm 
negative home 
pregnancy test prior to 
initiating new cycle 
Positive → serum 
hCG confirmed: 
Move to Pregnancy 
follow up track
Negative → Proceed with next cycle 

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1 KEY ROLES AND CONTACT INFORMATION 
Principal 
Investigator:   
Rachel Mejia, DO 
Clinical Assistant Professor, Division of Reproductive 
Endocrinology & Infertility  
University of Iowa Hospitals & Clinics 
200 Hawkins Drive, Iowa City IA 
319-384-5413 
Rachel-mejia@uiowa.edu 
 
Clinical Site 
Investigators: 
Jessica Kresowik, MD, University of Iowa, Quad Cities Clinic 
Abigail Mancuso, MD, University of Iowa, Jordan Creek Clinic 
Laura Cooney, MD, University of Wisconsin, Generations clinic  
 
 
Other Key 
Personnel: 
Brad Van Voorhis, MD 
Division Director of Reproductive Endocrinology & Infertility  
University of Iowa Hospitals & Clinics 
200 Hawkins Drive, Iowa City IA 
 
Karen Summers, MPH, CHES 
Research Coordinator 
Department of Obstetrics and Gynecology  
University of Iowa Hospitals & Clinics 
200 Hawkins Drive, Iowa City IA 
 
Patrick Ten Eyck, PhD 
Statistician 
Institute for Clinical and Translational Science 
University of Iowa 

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2 INTRODUCTION: BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE  
2.1 
Background Information 
Infertility in the US: The CDC National Survey of Family Growth (2011-2015) estimated that 7.3 million 
American women of reproductive age have used infertility services(1). Ovulatory disorders are the cause 
of approximately 30% of infertility(2). The most common ovulatory disorder, polycystic ovary syndrome 
(PCOS), comprises approximately 70% of anovulatory infertility cases(2). Based on these estimates, 
over 1.4 million American women have sought care for infertility related to PCOS. In this proposal, we 
focus on evaluating a novel cost- effective treatment strategy to improve fertility in women with PCOS. 
Current treatments for infertility and their limitations: Anovulatory disorders, specifically PCOS have been 
extensively studied, including significant research on oral ovulation induction agents by the NICHD 
Reproductive Medicine Network. This work has established letrozole as the first-line treatment for 
anovulation, due to superior delivery rates compared to clomiphene citrate (CC) (3). Although Letrozole 
is the preferred initial treatment, ovulation and delivery rates remain poor. For example, the PPCOS II 
trial demonstrated an ovulation rate over 5 treatment cycles of 61.7% with letrozole relative to 48.3% 
with CC, with live birth rates of 27.5% and 19.1%, respectively (4). Thus, over 70% of women will not 
achieve a live birth and will require more aggressive therapies. 
More aggressive therapies pose greater risks, particularly to the children conceived. The second-line 
treatment for women who fail to conceive with oral agents is gonadotropin ovulation induction (3), 
which carries a dramatically higher risk of multiple gestation as compared to oral ovulation induction 
agents. Eijkemans et al found a 13.6% multiple gestation rate among pregnancies conceived with 
gonadotropins in anovulatory women, with a 4.5% rate of higher order multiples (5). In contrast, in the 
PPCOS II trial, twins comprised 3.4% of pregnancies conceived with letrozole and 7.4% of pregnancies 
conceived with CC, with no higher order multiple gestations (4). Women who fail gonadotropin 
ovulation induction regimens will often proceed to in vitro fertilization (IVF). Multiple birth rates with 
IVF, although dropping, remain significantly higher than those seen with letrozole or CC, with twins 
comprising 13.7-17% of live births (6). Furthermore, pregnancy complications such as preterm delivery 
and low birth weight are increased in singleton IVF pregnancies (7, 8). 
Not only are risks increased with second- and third-line therapies, costs are also considerably higher. 
Gonadotropin ovulation induction has been estimated to cost an additional €3615 ($4121) per live birth 
compared with CC (9). Costs of IVF are estimated to be more than twenty times the cost of ovulation 
induction medication ($19,234 versus $912) (10). These estimates do not account for the increased 
costs related to care for multiple gestations. More cost-effective therapies for ovulation induction in 
women with PCOS are urgently needed, due to the relatively poor outcomes of existing first line 
therapies, and the high expense and multiple gestation rates of second- and third-line therapies. 
Mechanisms of drug action – potential for additive effect: CC is a non-steroidal selective estrogen 
receptor modulator that binds to the estrogen receptor in the hypothalamus. This central action affects 
the receptor recycling (11) and interferes with the normal feedback mechanism, resulting in increased 

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and prolonged FSH and LH secretion (12). These changes are more pronounced in the early follicular 
phase and are critical in initiating the development of follicles within the ovary. In a normo-ovulatory 
cycle, the rise in serum estrogen exerts a negative feedback in gonadotropin secretion. 
Unlike CC, letrozole has a peripheral action whereby it blocks aromatase and the cytochrome P450 
enzyme complex. This results in a peripheral hypo-estrogenic state, leading to increased FSH secretion. 
Letrozole also increases serum LH, androstenedione and testosterone levels (12). The rise in androgen 
levels increases follicular sensitivity to FSH by synergistic action with insulin-like growth factor (13-15) 
and FSH gene amplification (15, 16). The subsequent rise in serum estradiol provides a negative 
feedback on FSH, limiting multi-follicular recruitment and allowing endometrial proliferation (12). 
CC has an antiestrogenic effect on endometrial development, which has not been demonstrated with 
letrozole. It is important to evaluate and confirm that by combining these two medications we do not 
see thinning of the endometrium demonstrated by ultrasound. 
Herein we propose that the combination of letrozole and CC has an additive effect whereby CC decreases 
pituitary sensitivity to estrogen negative feedback while letrozole directly decreases serum estradiol, 
further promoting FSH secretion. We speculate that these alternate actions increase rates of ovulation 
and pregnancy in women with PCOS.  
 
Preliminary Data 
Addition of CC to letrozole improves ovulation rate: We investigated the impact of combining CC with 
letrozole as compared to letrozole monotherapy in 70 women with PCOS. We found that the 
combination of letrozole 2.5 mg and CC 50 mg nearly doubled the ovulation rate as compared to use of 
letrozole monotherapy (77% vs. 43%, P=0.007; rate ratio for ovulation (95% CI) 1.80 (1.18 to 2.75) (17). 
These results were achieved in a single treatment cycle, without any multiple gestations in our study 
cohort. In concordance with our findings, a prospective observational trial of combination letrozole and 
CC in patients who had previously failed CC and letrozole monotherapies found evidence of improved 
ovulation, with development of a dominant follicle in 
82.9% of cycles (18). While it is possible that the 
difference between the two arms in our preliminary 
study could be explained by a dosing effect, the 
ovulation rate in our combination treatment group was 
higher than the 61.7% cumulative ovulation rate across 
five cycles of letrozole monotherapy with increasing 
doses up to 7.5 mg (4). Our finding of a similar ovulatory 
rate within the letrozole monotherapy arm to that 
previously reported suggests an additive effect of the 
combination of these medications. 

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Addition of CC to letrozole does not negatively impact ultrasound parameters: Data from our pilot 
study suggest among the subgroup who ovulated, endometrial thickness and number of follicles were 
similar across treatment arms (Table 1). This is reassuring in that CC is not having a negative impact on 
the endometrium and 
multi follicular 
development appears 
limited. 
Both a commentary (19), 
and Fertility and Sterility 
Live Global Journal Club 
praised our pilot study, 
but 
emphasized 
the 
need 
for 
additional 
studies to evaluate escalating dosages, multiple cycles, live birth, and multiple gestation with this 
novel combination treatment. Given our promising initial data, the goal is to expand on our pilot and 
conduct a trial with escalating doses of letrozole across three cycles of either letrozole monotherapy or 
combination therapy in 184 women. This will provide not only additional data on ovulation rates but 
provide essential information on side effects, multiple gestation rate and live birth rate which will better 
situate us completing a multicenter study evaluating live birth rate.   
Significance and Innovation 
An improvement in the proportion of women with anovulatory infertility who conceive with oral 
ovulation induction agents is a public health imperative, as this increase can significantly reduce both 
the costs and complications of fertility treatments. We propose to study a novel method of oral 
ovulation induction with the combination of letrozole and CC. The mechanisms of ovulation induction 
differ when comparing letrozole (peripheral action at the ovary) and CC (central action in the 
hypothalamic-pituitary axis); therefore, it is reasonable to hypothesize that the two drugs combined 
have an additive effect. We have conducted the only randomized trial evaluating ovulation rates for 
this combination therapy compared to letrozole monotherapy. Our preliminary data demonstrate a 
nearly two-fold increase in ovulation rate with the combination of letrozole and CC, without evidence 
of an increase in the rate of multiple gestation (17). However, data comparing ovulation rates across 
multiple cycles with escalating Letrozole dosage is critically needed to plan a multi-center clinical trial 
to evaluate live birth rate. 
2.2 
Potential Risks and Benefits 
2.2.1 
Potential Risks 
Both letrozole and CC are used for the treatment of infertility.  Below is a table listing all 
tests or procedures involved in this research study and their related discomforts and 
risks.  
Table 1. Ultrasound characteristics among patients who ovulated 
Cycle Characteristics 
Letrozole Group 
n=14 
Letrozole + CC 
Group n=25 
p 
value 
# of follicles > 15 mm 
0.5 (0-1) 
1 (0-1.5) 
0.081 
Largest follicle size (mm) 
15.5 (10.0-18.3) 
17.0 (13.5-19.5) 
0.228 
Endometrial lining (mm) 
7.4 ± 2.3 
8.6 ± 3.9 
0.286 
*Data are presented as mean ± SD, or median (interquartile range) 

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Test or Procedure 
Discomfort and Risks 
Standard venipuncture for blood 
work 
Slight pinch or discomfort, bruising at the site of 
puncture, small blood clot, infection or bleeding at the 
site, and fainting during the procedure 
Transvaginal ultrasound 
Abdominal or pelvic discomfort 
Clomiphene Citrate 
Hot flashes, visual changes (blurring of vision, double 
vision, floaters), abdominal pain, nausea, vomiting, 
constipation, mood changes, headache, fatigue, multiple 
pregnancies, formation of ovarian cyst, breast 
discomfort, abnormal uterine bleeding, bloating, 
formation of ovarian cysts 
Letrozole 
Fatigue, dizziness, nausea, hot flashes, discomfort in 
your joints, back pain, increased cholesterol levels, 
formation of ovarian cysts, multiple pregnancies 
* Table is modified from PPCOS II trial 
It is expected that patients will not experience all of these side effects. Side effects 
associated with medications are temporary and manageable.   
Although the goal of treatment is to achieve pregnancy, there is no guarantee that 
treatment will result in pregnancy or a live birth.  CC has been associated with a 5-8% 
multiple pregnancy rate (7.4% twin pregnancy rate in PPCOS II) and Letrozole is 
associated with a 3.4% twin pregnancy rate in women with PCOS (PPCOS II data).  
The multiple pregnancy rate of the combination of these treatments is unknown. Multiple 
gestations are associated with preterm labor and delivery as well as most pregnancy 
complications including diabetes and high blood pressure.  
If pregnancy occurs it is possible that the pregnancy results in a non-viable pregnancy 
or tubal (ectopic) pregnancy.  In either of these cases occur, further medial or surgical 
treatment may be necessary.   
The incidence of congenital anomalies in the general population is 3% to 5%. In the 
PPCOS II trial comparing letrozole and CC there were a total of 5 congenital anomalies 
(1/66 in CC group – 1.5%, 4/102 in letrozole group 3.9%) (4).  
2.2.2 
Potential Benefits 
Possible benefits to participants: The potential benefit to the participants is that they 
will receive a treatment (letrozole) that is known to improve ovulatory and pregnancy 
rates in women with infertility secondary to anovulation compared to no treatment at all 
or CC alone.  The participant may receive a treatment (letrozole + CC) that may prove 
to be more effective than letrozole alone. Treatments may result in pregnancy although 
this cannot be guaranteed.  

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With ultrasound and hormone testing the participant may receive additional information 
regarding ovulation status.   
Possible benefits to others: The study will provide important information on the 
treatment for women with infertility secondary to anovulation.  This will provide 
knowledge on effective ovulation treatments for this patient population. The knowledge 
gained from this research may help discover an effective and safe way to achieve 
ovulation and pregnancy.   

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3 OBJECTIVES 
3.1 
Primary Research Hypothesis 
The primary research hypothesis is that ovulation induction with the combination of 
letrozole and clomiphene citrate is more likely to result in ovulation (increased ovulation 
rate) than ovulation induction with letrozole alone in infertile women with anovulation 
(PCOS and/or normogonadtropic normoestrogenic anovulation or oligo-ovulation).    
3.1.1 
Primary Outcome Measure 
The primary outcome measure is the occurrence of ovulation during the study period.  
Ovulation is defined as a mid-luteal progesterone level > 3 ng/mL. This will be tested 6-
8 days following the patient reporting of an LH surge. If no LH surge is detected the lab 
will be drawn on cycle day 21-24. We will also analyze the ovulation rate of the follow up 
progesterone level.  
We will utilize an intent-to-treat approach for the primary analysis of ovulation rate 
(utilizing the first progesterone level of each cycle) within the two treatment arms.  If it is 
determined that timing of the initial progesterone level is inaccurate based on LH testing 
or patient symptoms, the progesterone test that is most clinically in line with accurate 
timing (6-8 days post LH surge) will be used.  Ovulation rate will also be reported in those 
with a delayed response to treatment (needed repeat progesterone level due to 
anovulatory mid-luteal P4 level and follicle > 14 mm). Patients will be analyzed according 
to the treatment group to which they are assigned, even if they did not receive the 
intended treatment or received only a portion of it.  We will also perform a per protocol 
analysis to include only those patients who initiate treatment.  Thus, those that are 
randomized but do not take the treatment due ineligibility will be excluded from the per 
protocol analysis.  This per protocol analysis will provide data that is helpful to clinicians 
as it will include only those who initiated treatment.   
3.2 
Secondary Research Hypothesis and outcome measures 
We will analyze secondary outcomes however due to sample size will not be able to 
power differences in pregnancy rate and live birth rate.  Descriptive secondary 
outcomes will include positive pregnancy test, clinical pregnancy, and ongoing 
pregnancy. We will also evaluate number of corpora lutea determined by ultrasound, 
endometrial thickness and pattern by ultrasound. We will also monitor adverse events 
during treatment and side effect profile of both treatment arms.  
We will evaluate pregnancy outcomes and report any fetal anomalies.   
1. The combination treatment will result in higher live birth rate 
a. Outcome measurement: live birth rate 

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2. The shortest time to pregnancy will be with the combination treatment. 
a. Outcome measurement: time to pregnancy 
3. Treatment with the combination will have a similar singleton pregnancy rate 
compared to treatment with letrozole.   
a. Outcome measurement: Singleton pregnancy and singleton pregnancy 
rate; singleton pregnancy is defined as presence of single intrauterine 
gestational sac with a single fetal pole and observable heart motion.  
Multiple pregnancy rate will also be compared.   
4. Treatment with the combination will have a similar pregnancy loss rate compared 
to treatment with letrozole.  
a. Outcome measurements: Pregnancy loss (defined as spontaneous abortion 
occurring before 13 weeks gestation), biochemical (positive hCG test with 
spontaneously dropping hCG levels), ectopic pregnancy or pregnancy of 
unknown location 
5. Side effect profile will be similar between both treatment groups. 
a. Outcome measurements: # of days of reported side effects and 
acceptability of side effects.  
6. Endometrial thickness and corpora lutea number will be similar between the two 
groups. 
a. Outcome measurement: Endometrial thickness and corpora luteal number 
on CD21-23 transvaginal ultrasound or approximately 6-8 days following 
detection of LH surge. These outcomes will also be evaluated based on 
dosing.   

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4 STUDY DESIGN 
4.1 
Treatment Design 
This will be a multicenter, open trial of oral letrozole versus combination of oral letrozole  
and clomiphene citrate for the treatment of infertility in patients with oligo-ovulation or 
anovulation. Patients will be randomized to one of two treatment arms, to receive either 
an initial dose of letrozole 2.5 mg alone or clomiphene citrate 50 mg and letrozole 2.5 mg 
for 5 days during their menstrual cycle.  Letrozole dosing will be escalated in a stair-step 
fashion based on ovulation results.  Max dose of letrozole will not exceed 7.5 mg.   
Participation in active treatment will last for up to 3 treatment cycles, approximately up to 
15 weeks.  Participants will be monitored at monthly intervals during expected mid-luteal 
phase to evaluate response to medication by evaluating ultrasound and progesterone 
parameters.  
The dose will be adjusted according to response at mid-luteal visit.   
- 
Anovulatory progesterone level < 3 and no evidence of follicular development 
and corpora lutea→ increase letrozole dose on that day.  This would be 
considered start of new treatment cycle (CD3).   
- 
Anovulatory progesterone level < 3 with evidence of follicular development 
(follicle >14 mm) → repeat progesterone level based on LH testing (6-8 days 
following positive) or at 2 weeks if no positive → increase dose at menses visit 
(2nd progesterone is ovulatory) or increase dose at time of second progesterone if 
level < 3.  
- 
Progesterone level >3 → maintain same dose for next treatment cycle 
Anytime ovulation induction medication is started, pregnancy test to be performed prior 
to initiation of new treatment cycle.   
Randomization will be stratified by site, age (< 35 versus > 35) and BMI (< 30 and > 30) 
to ensure similar comparison groups in these characteristics that highly impact 
outcomes.  Randomization will be via a computer based central randomization to 
ensure adequate allocation concealment.  
Enrollment will take approximately 20 months if ~ 10 subjects are enrolled per month. 
Active subject participation will be through completion of 3 cycles.  We will follow up with 
patient regarding pregnancy and delivery outcomes.    
As previously mentioned, this is an open trial.  Patient will be aware of the treatment 
intervention they are receiving.  Currently, letrozole is considered the current standard 
of care/first line agent for WHO class II anovulation (women with PCOS).  Both groups 
will be receiving at minimum the current standard of care treatment.   

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4.1.1 
Rationale for dosing approach 
The dosing approach has been designed to escalate the letrozole dosing in subsequent 
cycle if participants do not ovulate.  Since aromatase inhibitors are the first line agent for 
women with PCOS we elected to first study the increase in this compared to the 
combination of letrozole and CC.  Consideration was given to varying doses of CC as 
well, however, results would be challenging to interpret with two varying doses and 
would not be clear if it was the increase of one medication or another that impacted 
ovulatory rate.  By keeping CC dose constant, we can assess the standard treatment of 
letrozole compared to the standard treatment with CC addition at constant dose.   
Stair step approach was also selected since we will be assessing progesterone and 
follicular status on ultrasound during luteal phase.  Stair step approach will keep patient 
treatment progressing rather than waiting for menses or inducing menses with progestin 
which, both which delay the next treatment cycle.   
 
4.2 
Study Summary 
Pre-screen: If patient is interested in hearing about the study, initial pre-screen will be 
performed to confirm basic eligibility criteria.  If general eligibility criteria is met, screening visit 
will be scheduled or initiated.  This may be part of the Screening visit/period. 
 
Screening visit/period:   
1. Study staff review pre-screening questionnaire 
2. Review and obtain informed consent  
3. Confirm eligibility criteria – Inclusion/Exclusion criteria (RedCap Form) 
 
4. Confirm documentation/abstract from medical record (RedCap form provided): 
a. Demographics, medical history 
b. Physical exam: vital signs, height, weight and BMI, hirsutism assessment 
c. Transvaginal ultrasound 
d. Assessment of other infertility factors: tubal and uterine factor, male factor, 
severe endometriosis 
e. Inclusion laboratory testing 
5. Pre-conception counseling: weight loss (BMI >30), tobacco cessation, folic acid use, 
rubella/varicella documentation, genetic carrier screening options 
6. If progestin withdrawal bleed necessary, progestin prescription provided and will be 
instructed when to take it.   
a. Progestin withdrawal bleed left to discretion of the provider 
b. Progestin withdrawal induced if no menses greater than 3 months 
 
Baseline visit/Randomization visit: 
Baseline visit will be scheduled during cycle day 1-3 (can go up to cycle day 5) following 
spontaneous menses or following progestin withdraw bleed.  Visit can also be a random start if 
anovulatory progesterone and no follicular development on ultrasound.   

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1. Urine pregnancy test 
2. Randomization once negative pregnancy test (no follicular development and anovulatory 
progesterone in cases for random start) 
3. Dispense study medication 
4. Review medication directions (handout provided) and journal log instructions (encourage 
online, paper is an option) 
5. Completion of baseline questionnaires (GAD-7, PHQ9, Ferti-QoL, and Perceived Stress 
Scale) or instructions provided on how to complete online 
6. Confirm completion and obtain information if needed for RedCap Baseline Abstraction 
form  
 
Monthly Midluteal visit (18 to 26 days following initiation of medication), up to 3 mid-
luteal visits.  Timing will be based on LH testing, ideally around 7-8 days post-positive 
test and if no positive test, CD 20-24.  
1. Transvaginal ultrasound 
2. Progesterone lab draw 
3. Dispense home urine pregnancy test 
4. Collect and review journal logs (side effects, menstrual logs, intercourse log, 
concomitant medications, completion or missing entry)  
5. Count medication and confirm contact method for informing participant of plan based on 
lab and pregnancy test at end of cycle.   
6. Medication dispensed for next cycle or patient may return on CD1-3 (preferable if able).   
Instructions based on progesterone level and ultrasound results: 
1. Progesterone level > 3 ng/mL → instruct participant to await menses and perform 
pregnancy test with menses or if no menses, perform pregnancy test 2 weeks after 
midluteal visit. 
2. Anovulatory progesterone level < 3 ng/mL and with evidence of follicular development 
(mean follicle size > 14 mm → repeat progesterone level in 10-14 days. 
a. If repeat (2nd P4) is ovulatory progesterone level > 3 ng/mL → increase treatment 
dose next cycle with menses after negative pregnancy test 
b. If repeat (2nd P4) is anovulatory progesterone level < 3 ng/mL → increase 
treatment dose and initiate next cycle after negative pregnancy test.  
3. Anovulatory progesterone level < 3 ng/mL and no evidence of follicular development or 
corpora lutea → increase ovulation medication on that that day after negative pregnancy 
test. This is considered the start of a new cycle. Next mid-luteal clinic visit would be 
scheduled for 7-8 days following positive LH test or 18 to 26 days following initiation of 
medication.   
 
Menses check in appointment (via RedCap) 
- 
This check in is necessary in order to initiate next cycle.  At onset of menses, each 
participant will take a home pregnancy test and complete the RedCap form indicating 
“Negative Pregnancy test”.  If no menses within 2 weeks after the midluteal visit, 
participants will take a pregnancy test.  

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o If positive urine pregnancy test, lab visit scheduled for serum hCG level and 
repeat in 48-72 hours.  
o If negative urine pregnancy test, start medication on Cycle day 3 of menses 
- 
Submit journal logs via email or in person 
Pregnancy lab Visits (part of standard of care) 
- 
If positive urine pregnancy test, lab visit scheduled for serum quantitative hCG level and 
repeat in 48-72 hours.  
- 
Appropriate rise: 
o 2 day rise – multiply level x 1.7 
o 3 day rise – multiple level x 2.3 
o 4 day rise – multiply level x 2.89 
- 
If appropriate rise, schedule Transvaginal ultrasound at 6 to 7 weeks and visit with 
provider. 
- 
If inappropriate rise, schedule early ultrasound (no earlier than 5 4/7 weeks) to confirm 
IUP and then follow up ultrasound based on initial ultrasound results.  Timing of scan 
can be based on local protocol.  
o At UW, a 5 week ultrasound will be scheduled to confirm IUP and then follow up 
ultrasound based on initial ultrasound results 
 
 

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5 STUDY ENROLLMENT AND WITHDRAWAL 
5.1 
Study Population 
184 women with WHO class II anovulation/PCOS actively seeking pregnancy (or 92 per 
each treatment arm) aged > 18 to < 40 years will be randomized.  The overall goal of 
enrollment criteria is to identify a population of healthy women with anovulatory or oligo-
ovulation (WHO Class II anovulation) and infertility not specified by another cause. 
Infertility will be determined by clinical history. PCOS will be determined by including 
two of three findings: oligo- or anovulation, hyperandrogenism or polycystic ovaries on 
ultrasound.  Definitions are from the 2018 Recommendations from the international 
evidence-based guideline for the assessment and management of polycystic ovary 
management(3). 
• Oligo-ovulation: cycles less than 21 days or greater than 35 days or less than 8 
cycles per year 
o Ovulatory dysfunction/Anovulation: women with regular cycles with 
anovulatory progesterone or with amenorrhea 
• Polycystic ovarian morphology (PCOM) on ultrasonography: follicle number 
(measuring 2-9 mm) per ovary of > 20 and/or ovarian volume >10 ml on either 
ovary, ensuring no corpora lutea, cysts or dominant follicles are present if using 
volume only.  
• Hyperandrogenism: determined by evidence of clinical or biochemical 
hyperandrogenism 
o Clinical: symptoms and signs of hirsutism, acne or alopecia 
o Biochemical: elevations in calculated free testosterone or free androgen 
index (Total Testosterone level divided by SHBG level and multiply by 
100). Levels should not have been assessed while on combined hormonal 
contraceptive  
• If PCOS criteria is not met, normogonadotropic anovulation should be met 
with confirmation of anovulation/olig-ovulation and normal FSH and 
estradiol levels.    
• Infertility: Inability of couple to achieve successful pregnancy after 12 months of 
regular timed unprotected intercourse in women less than 35 years of age; and 
after 6 months of regular intercourse without use of contraception in women 35 
years and older(20). If in the clinical case of anovulation/oligo-ovulation, 12 
month period of time “infertility” is not necessary.   
 

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5.2 
Subject Inclusion Criteria 
In order to be eligible to participate in this study, an individual must meet all of the 
following criteria: 
1. Diagnosis of infertility (described above) 
2. Normogonadotropic normoestrogenic (WHO Group II) anovulation or 
oligo-ovulation: 
a. Diagnosis of PCOS as described above 
OR 
b. Self-reported menstrual cycle length < 21 or > 35 days or < 8 cycles 
per year. For women with variable cycle length not consistently <21 
days or >35 days, a serum progesterone between day 21 and 35, 
<3 ng/ml will be considered evidence of oligo-ovulation AND normal 
estrogen level and FSH level 
3. Age 18-40 
4. BMI < 50 
5. Normal semen analysis in past two years according to World Health 
Organization cut off points (concentration and motility) or a total motile 
sperm count greater than 10 million.  Morphology results will not affect 
eligibility.  If male partner has fathered a child, SFA is not necessary.   
6. Desire to achieve a pregnancy 
7. Willing to comply with study procedures for the duration of the study.  
Ability to have intercourse at least twice weekly and follow study protocol 
5.3 
Subject Exclusion Criteria 
An individual who meets any of the following criteria will be excluded from participation in 
this study: 
1. Current pregnancy 
2. Current use of oral contraceptives, injectable contraceptives, implanted 
hormonal contraceptives, or oral, vaginal or transdermal estrogens or 
progestins.  1-month washout required, 3 months for injectable/implanted 
progestin contraceptives.  
3. Patients with other known cause of infertility: endometriosis, tubal factor, 
diminished ovarian reserve (defined as AMH < 1 or AFC < 10), uterine 
abnormalities. 
a. Patients with unilateral tubal patency can be enrolled, provided at 
least one tube is open. 
b. Patients with mild endometriosis can be enrolled 
4. Uncontrolled thyroid disease (normal TSH in past 3 years is adequate).  

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a. Patients with uncorrected thyroid disease defined based on their 
local lab or at UIHC (0.27 to 4.20 µIU/mL). Once corrected and 
within this range, they may be enrolled if the other inclusion and 
exclusion criteria are met.  A normal lab within the last 3 years is 
adequate for entry 
5. Hyperprolactinemia (prolactin > 30 ng/dl x 2). A normal prolactin within the 
past year at local lab or at UIHC (4.8 to 23.3 ng/mL) is adequate for entry 
if history of hyperprolactinemia. 
6. Medical conditions in which we recommend avoiding pregnancy until 
under improved control 
a. Patients with poorly controlled Type 1 or Type 2 diabetes (defined 
as a hemoglobin A1c > 6.5-7.0%) 
b. Uncontrolled hypertension (medicated or unmedicated, BP 
>160/100 x 2) 
c. Bariatric surgery within the past year 
d. Untreated endometrial hyperplasia 
e. Current alcohol use > 14 drinks per week 
7. Patients with contraindications to clomiphene citrate: hypersensitivity to 
CC or any of its components, history of liver disease or known liver 
disease (LFT’s are not necessary prior CC use and enrollment into the 
study), unknown cause of abnormal uterine bleeding, intracranial lesion. 
8. Patients with contraindications to letrozole: hypersensitivity to letrozole or 
any of its components.   
9. Patients taking medications known to affect reproductive function or 
metabolism or that are an absolute contraindication during pregnancy. 
a. Patients taking Metformin can be enrolled, provided they have 
documented impaired glucose tolerance or insulin resistance. 
Patients who are not taking Metformin for these indications will be 
excluded. 
 
10. If patients are suspected based on clinical findings for other etiologies that 
mimic PCOS, work up must be completed to exclude other etiologies prior 
to enrollment (i.e. Cushing’s syndrome, androgen-secreting tumor). 
11. Prior diagnosis of congenital adrenal hyperplasia or Cushing’s Disease or 
Syndrome 
5.4 
Strategies for Recruitment and Retention 
 
Strategies for Recruitment 
Potential study participants will be recruited from couples seeking fertility evaluation 
and/or ovulation induction at participating fertility clinics and other referring practices 
providing reproductive care. Study team members will review clinic schedules for their 

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center and will be approached regarding the study by their clinician, a study coordinator, 
or another member of the research team while at the clinic for their initial consult or 
clinical visit. Couples will be given information about the study, offered pre-screening to 
assess eligibility, and given the opportunity to schedule an enrollment visit.    
 
Study information materials and contact information will be provided to outside and 
community clinics that commonly refer patients to participating study centers. A study 
coordinator or another member of the research team will review study information and 
assess eligibility with couples referred to the study from external clinics, 
clinicaltrials.gov, word of mouth, or other external sources. 
  
Recruitment at UW- Recruitment will occur in the clinical setting through posters, 
brochures, digital posters displayed at UW Health Clinics, and referral in both the 
Department of Obstetrics and Gynecology and the UW Health Generations Fertility 
Clinic through conferencing software. If a patient hears about the study from a referring 
provider or someone not on the research team, the referring provider will direct the 
patient to contact the research team if they are interested in participating or hearing 
more about the study. The referring provider will provide recruitment materials so that 
the patient can contact the team directly.  
 
Recruitment strategies for individual sites have been approved by local IRBs. 
 
 
Strategies for Retention 
Study coverage of ovulation induction medication and ultrasounds are expected to be 
sufficient incentive for participation in the study. Additional measures to retain subjects 
for up to three cycles of ovulation induction will involve establishment of positive rapport 
between the study team and participants, appointment and scheduling reminders, and 
regular communication regarding ultrasound and lab results.  
 
Participants will be given the opportunity to schedule future study visits during the 
preceding study visit or any time prior to the study visit. Participants will receive an 
appointment reminder within the week prior to their scheduled appointment. Study staff 
will utilize a system of reminder emails and phone calls to contact participants who need 
to schedule their next study visit of if a study visit is missed.  
 
Retention strategies for pregnancy outcome data will involve obtaining consent to 
release information forms at participant enrollment visits, and study team confirmation of 
the participant’s planned obstetric care provider when pregnancy is detected. In the 
event that an updated consent to release information form is not on file post-delivery, 

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study staff will utilize a system of reminder emails, phone calls, and mailed 
correspondence to obtain an up-to-date form. This system will involve an initial email 
and two mailed letters with request for completion of forms, with each email request and 
mailed letter request followed by two phone calls in the case of participant non-
response. 
 
Consent to obtain information forms for infants born during study follow up will be 
obtained following delivery.  
 
At the University of Iowa- Study staff will utilize a follow up system of reminder 
emails, phone calls, and mailed correspondence to obtain parental consent to 
release information for infants. This system will involve an initial email and two 
mailed letters with request for completion of forms, with each email request and 
mailed letter request followed by two phone calls in the case of participant non-
response. 
 
At the University of Wisconsin- At the time of consent, the subject will sign a 
consent form that includes consent to obtain information from the newborn’s 
medical record. A release of information form to obtain information for neonates 
born during study follow up will be obtained when the subject becomes pregnant. 
Study staff will have these forms explained and completed at a standard clinical 
visit or virtually 
 
 
5.5 
Treatment Assignment Procedures 
Participants will be assigned to either combination letrozole and clomid or letrozole 
monotherapy in a 1:1 allocation ratio. Randomization will be blocked (with random 
sequences of block sizes 2, 4 and 6) and stratified by age (< 35 versus > 35), body mass 
index (<30 and >30), and site to ensure that balance between the treatment groups within 
age, BMI, and site is maintained over the enrollment period. 
5.5.1 
Randomization Procedures  
Participants will be randomized using randomization tables generated by a statistician 
and uploaded to the project in RedCap.  The randomization scheme will not be accessible 
to study staff in order to maintain allocation concealment. Study staff will randomize 
subjects by entering BMI category (<30 or 30+), age category (<35 or 35+) and site on 
the RedCap Randomization page. Once these fields are entered and confirmed to be 
accurate, staff will click the “Randomize” button under treatment group to receive the 
participants assigned treatment.”   

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5.6 
Subject Withdrawal 
Subjects may withdraw voluntarily from the study or the investigator may terminate a 
subject’s participation.   
5.6.1 
Reasons for Withdrawal 
Subjects are free to withdraw from participation in the study at any time upon request. 
An investigator may terminate a study subject’s participation in the study if: 
• Any clinical adverse event (AE), laboratory abnormality, or other medical condition 
or situation occurs such that continued participation in the study would not be in 
the best interest of the subject. 
• The subject meets an exclusion criterion (either newly developed or not previously 
recognized) that precludes further study participation. 
• The study is terminated 

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6 STUDY INTERVENTION 
6.1 
Study Product Description 
Study medications, letrozole and clomiphene citrate will be purchased through the 
University of Iowa Research pharmacy.  Letrozole comes in 2.5 mg tablets and CC comes 
in 50 mg tablets.   
6.1.1 
Formulation, Packaging, and Labeling 
Letrozole will be packaged based on dosage indicated per the study protocol.  Letrozole 
2.5 mg (5 total tablets) will be supplied for the first cycle for all participants.  Letrozole 
dose will be increased if patient did not ovulate on the dose prescribed or had significantly 
delayed ovulation based on the protocol.  If prescribed Letrozole 5.0 mg, 10 tablets will 
be prescribed and if prescribed Letrozole 7.5 mg, 15 tablets will be prescribed.  The total 
dosage per cycle needed will be provided in one vial with a medication label. 
If the patient is in the combined group, they will receive letrozole mediation as above and 
also receive CC 50 mg (5 tablets).  This will be packaged in its own vial with a medication 
label.   
All medications will be dispensed  in containers which meets the requirements of the 
Poison Prevention Packaging Act of 1970, 15 U.S.C. ss. 1471-1476 (2001), unless 
otherwise requested by the subject, and of Section 502G of the Federal Food, Drug and 
Cosmetic Act, 21 U.S.C. ss. 301 et seq. (2001). 
Preprinted adhesive medication labels will be affixed to the container(s) in which the drug 
is dispensed. Labels will include: name, address, and phone of prescribing physician; 
name of patient; date dispensed; directions for administering the prescription medication; 
expiration date, and name and strength of the prescription drug in the container. Labels 
will be edited by each site to comply with local regulations. Example labels where patient 
name, dispense date and prescribing physician and location can be filled when 
dispensing are as follows: 
Clomiphene 50mg: 
 
 
 
 
Name:  
 
 
 
Date: 
 
Take 1 tablet daily on cycle days 3 through 7. 
Clomiphene Citrate tablets 50 mg 
Total tabs #5 
CLC II Study 
Dr:  
 
 
 
 
UIHC-1360 N Dodge Iowa City, IA, 52242 
319-384-5413 

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Letrozole 2.5mg: 
 
 
 
Letrozole 5.0mg: 
  
 
 
Letrozole 7.5mg: 
 
 
 
 
6.1.2 
Product Storage and Stability 
Study medications will be stored at each site in a locked room in a locked cabinet and be 
inaccessible to unauthorized personnel. Study medication will be stored at room 
temperature, with temperature tracked by a min/max thermometer with temperatures 
recorded weekly in a temperature log.  
Letrozole should be stored at 20˚ to 25˚C (68˚ to 77˚ F) and Clomid at 15˚ to 30˚C (59˚ to 
86˚ F). 
Expiration date from the original vial will be included on the medication label.  Prior to 
dispensing, dispenser will ensure expiration time has not elapsed prior to dispensing.   
At University of Wisconsin storage of the drugs will be according to the UW Health 
Administrative (non-clinical) Investigational and Study Drug Control policy.  
 
6.2 
Administration of Study Product 
University of Iowa Study Team will deliver medication to satellite recruiting clinics.   
Name:  
 
 
 
Date: 
 
Take 1 tablet daily on cycle days 3 through 7. 
Letrozole tablets 2.5 mg 
Total tabs #5 
CLC II Study 
Dr:  
 
 
 
 
UIHC-1360 N Dodge Iowa City, IA, 52242 
319-384-5413 
Name:  
 
 
 
Date: 
 
Take 2 tablets daily on cycle days 3 through 7. 
Letrozole tablets 2.5 mg 
Total tabs #10 
CLC II Study 
Dr:  
 
 
 
 
UIHC-1360 N Dodge Iowa City, IA, 52242 
319-384-5413 
Name:  
 
 
 
Date: 
 
Take 3 tablets daily on cycle days 3 through 7. 
Letrozole tablets 2.5 mg 
Total tabs #15 
CLC II Study 
Dr:  
 
 
 
 
UIHC-1360 N Dodge Iowa City, IA, 52242 
319-384-5413 

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The medication will be dispensed to the patient by one of Study Team members.  
Verification of correct tablet number, correct packaging and expiration date will be 
performed prior to dispensing.   
6.3 
Accountability Procedures for the Study Product 
All received and dispensed medications will be documented on medication logs 
maintained by each study site.  Record logs must comply with applicable regulations and 
guidelines and should include:  
- 
Drug name and strength, Manufacturer, and Lot Number 
- 
Date and Quantity Received  
- 
Date and Quantity Dispensed, Subject ID, Name of prescriber, and Dispenser’s 
initials 
- 
Date and Quantity Returned by Subject 
- 
Date and Quantity Stock Destroyed 
- 
Dates and Findings of Inventory Checks   
6.4 
Assessment of Participant Compliance with Study Product Administration 
Participant compliance will be assessed with questionnaires and pill counts. Participants 
will be asked to report the number of pills taken per day on their journal log. Participants 
will also be asked to bring their pill bottles with any remaining medication to their mid-
luteal and end-of-treatment visits. Study staff will perform pill counts at each study visit. 
Study staff will perform pill counts outside of the room where the participant is located 
when possible.  
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7 STUDY SCHEDULE 
A diagram of the Schedule of Events is provided in Appendix A.  
7.1 
Screening 
Screening Visit  
• Obtain and document consent from potential subject on screening consent form. 
• Review medical history to determine eligibility based on inclusion/exclusion 
criteria. 
• Review medications history to determine eligibility based on inclusion/exclusion 
criteria. 
• Review when to schedule study enrollment visits for individuals who are eligible 
and available for the duration of the study.  
o Cycle day 1-3 or  
o At random once pregnancy and recent/imminent ovulation and follicular 
development are excluded (no follicular development on ultrasound and 
anovulatory progesterone) (within a week of these studies) 
• At University of Wisconsin, A consenting visit will be scheduled on a day when the 
potential subject has availability, after she has reviewed the consent form. This 
visit will be done by video conferencing so the coordinator can witness the subject 
signing the consent form. 
 
o During the remote visit, if eligibility has been confirmed, the coordinator may 
complete informed consent. The identity of the subject will be verified during 
the e-visit that will be set up for remote consenting. During this visit, 
conducted via video conference, the coordinator will ask the patient to say 
her name and DOB to identify herself. Confirmation of the subject's identity 
can be recorded in a memo in the patient’s study record. The subject will 
electronically sign the consent form through DocuSign. Email permission 
will be obtained before sending the electronic consent form to the potential 
participant as there is an email permission comment in the phone script, 
 
o The date and time of the consent, along with the people who are present 
and the method of consent, will be documented in a memo for each subject. 
Upon receipt of the signed consent form, the coordinator will complete the 
consent by signing and dating both forms. At this point, the subject is 
enrolled. The coordinator will contact the clinical staff about the enrolled 
subject. 

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7.2 
Enrollment/Baseline 
The enrollment/baseline visit will be scheduled when participants are on Cycle day 1-3 of 
their cycle or when ready to begin taking medication after pregnancy and recent/imminent 
ovulation have been excluded. All participants must have a negative urine pregnancy test 
prior to randomization. 
Enrollment/Baseline Visit (Cycle Day 1-3 or at random as noted above) 
• Obtain and document consent from subject on study consent form. 
• Verify inclusion/exclusion criteria. 
• Obtain a urine pregnancy test and confirm negative result. 
o Participation will be concluded at this point for participants with a positive 
urine pregnancy test; however, if a miscarriage results, participants can 
continue participation   
• Review medical history and record in participants record in RedCap 
• Assign participant ID 
o Participants IDs are assigned sequentially by site, with a 5 digit ID 
comprised of two components: 
▪ The first 2 digits of the ID are assigned based on the participant’s 
primary study site: 
• Iowa City: 01 
• Quad Cities: 02 
• University of Wisconsin: 03 
• Des Moines: 04 
▪ The final 3 digits of the ID are assigned based on where the 
participant falls sequentially in enrollment at that site. 
• Ex. The first participant at Iowa city would be 01001, the 
second at this site 01002, the third 01003 etc. 
• The next sequential number for the site can be identified by 
viewing the “Participants enrolled” report in RedCap and 
filtering on the participant’s primary site. The assigned 
number should follow the final number on the report for that 
sites sequence. 
• Randomize participant in RedCAP to determine treatment allocation  

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• Dispense study medication for initial cycle 
• Review instructions on how to complete the calendar log and how to take study 
medication 
o Participants should complete the calendar log to document sexual activity, 
side effects, and LH surge beginning the first day they take the study 
medication. Calendar logs are available on RedCAP and weekly links for 
the calendar log will be sent to the participant’s email after randomization. 
Subjects who do not wish to complete the calendar log electronically will 
have the option of completing on paper and returning to study staff at their 
next visit. 
o Participants should take the study medication on cycle day 3 through 7 for 
a total of 5 days. If participants are unable to begin the medication on cycle 
day 3, they may begin on cycle day 4 or 5, but should begin medication no 
later than cycle day 5. Participants who meet criteria for random start will 
take the medication for 5 days at random start, with the first day of 
medication considered cycle day 3. 
• Have participant complete baseline questionnaires (GAD7, PHQ9, FertiQoL, and 
Perceived Stress Scale, or if participant prefers to complete online, provide 
instructions on completing forms after visit 
• Obtain a consent to obtain medical information from the participant if medical 
records will need to be obtained from an external provider for either fertility 
treatment chart abstraction and/or for potential future pregnancy chart abstraction 
7.3 
Intermediate Visits 
Participants will return for a midluteal study visit on cycle day 21-24 or 7-9 days following 
positive ovulation prediction test to determine if ovulation occurred. This visit will include 
an ultrasound and a progesterone lab.  
If there is no ovulation, the daily dose of letrozole will be increased by 2.5 mg, to begin 
immediately. During the first cycle after letrozole dose increase, participants would 
receive 5mg daily for 5 days. If participants receive a second letrozole dose increase, 
they would receive 7.5 mg Letrozole daily for 5 days. The maximum dose for Letrozole in 
this study is 7.5 mg. CC 50 mg will be given on the same days as the letrozole in all cycles 
in the combination arm. Midluteal visits will be performed in all cycles. Each participant 
will complete a maximum of 3 cycles of medical therapy. On average we expect this to 
be about 4 months time, however, delayed ovulation, a biochemical pregnancy, or 1st 
trimester pregnancy loss in the first or second treatment cycle could delay the start of 
subsequent 
cycles, 
and 
therefore 
would 
extend 
active 
participation.  
 

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Cycle 1 Midluteal Visit  
Timing will be based on LH testing, ideally around 7-8 days post-positive test or 
CD21-24 if no positive test 
• Transvaginal ultrasound to assess for corpora lutea and endometrial thickness and 
pattern 
• Serum progesterone assessment for ovulation 
• Review subject calendar log and record adverse events as reported by subject or 
observed by investigator. 
• Determine dosage for next cycle based on ultrasound and progesterone results 
and record in RedCap 
o If there is no ovulation, the daily dose of letrozole will be increased by 2.5 
mg (5mg). The combination arm will continue to receive CC 50mg along 
with the increased letrozole dose. 
o If there is ovulation, treatment will be repeated in the next cycle with the 
same dose of letrozole. The combination arm will continue to receive CC 
50mg along with letrozole 2.5mg.  
• Schedule a follow up Progesterone lab if necessary 
o Participants with anovulatory progesterone levels (<3 ng/ml) and evidence 
of follicular development will return for a repeat progesterone level 
assessment in 10-14 days. 
o Participants with elevated anovulatory progesterone levels (1.5 < P4 < 3.0) 
and corpus luteum on ultrasound will return for a repeat progesterone level 
assessment in 2-3 days  
• Dispense pregnancy test and medication for next cycle and review instructions for 
medication (dispense medication if unable to return to pick up meds, if can easily 
return, have participant return for med pick up) 
o Participants without ovulation nor evidence of follicular development are to 
complete pregnancy test and begin medication at new dose immediately 
following negative pregnancy test 
o Participants with ovulation are to wait until onset of menses, or two weeks 
after midluteal visit to complete pregnancy test. They can begin medication 
at same dose following negative pregnancy test. Participants with a positive 
pregnancy test will be moved to pregnancy track and will return dispensed 
medication at their next study visit.  

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• Collect any unused medication from current cycle and document participant 
compliance in RedCap 
• Record results of ultrasound and serum progesterone in RedCap 
Cycle 1 Follow-up Midluteal Visit*  
Participants with anovulatory progesterone levels (<3 ng/ml) and evidence of follicular 
development at their midluteal visit will return for a repeat progesterone level 
assessment in 10-14 days. This can be performed at a local lab if the participant 
prefers. 
• Serum progesterone assessment for ovulation 
• Review subject calendar log and record adverse events as reported by subject or 
observed by investigator. 
• Review instructions for previously dispensed medication/dispense medication if 
not yet dispensed 
o Participants without ovulation are to complete pregnancy test and begin 
medication at new dose following either a spontaneous menses or withdraw 
bleed and a negative pregnancy test. They can begin taking medication to 
induce a withdraw bleed on cycle day 35, following a negative pregnancy 
test. 
o Participants with ovulation are to wait until onset of menses, or two weeks 
after midluteal visit to complete pregnancy test. They can begin medication 
at new dose following negative pregnancy test (if ovulation did not occur on 
or before cycle day 21). Participants with a positive pregnancy test will be 
moved to pregnancy track and will return dispensed medication at their next 
study visit.  
▪ Participants who were initially anovulatory at a study visit prior to 
cycle day 21, who are ovulatory at a follow up visit by cycle day 21 
will be maintained on the same dose of medication. This may occur 
if participant’s study visit was moved up due to an early false positive 
ovulation prediction test. 
• Record results of serum progesterone in RedCap 
Cycle 1 Menses Check-In/Cycle 2 Start (menses from Cycle 1)*  
Two weeks post Midleuteal visit if no menses before then 

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Participants with ovulation are to wait until onset of menses, or two weeks after 
midluteal visit to complete pregnancy test. They can begin medication at new dose 
following negative pregnancy test.  This visit can be completed remotely with 
participant logging information in RedCap. If they don’t have medication, they will 
come in to pick it up. Participants with a positive pregnancy test will be moved to 
pregnancy track and will return dispensed medication at their next study visit.  
Cycle 2 Midluteal Visit  
Timing will be based on LH testing, ideally around 7-8 days post-positive test or 
CD21-24 if no positive test. 
• Transvaginal ultrasound to assess for corpora lutea and endometrial thickness and 
pattern 
• Serum progesterone assessment for ovulation 
• Review subject calendar log and record adverse events as reported by subject or 
observed by investigator. 
• Determine dosage for next cycle based on ultrasound and progesterone results 
and record in RedCap 
o If there is no ovulation, the daily dose of letrozole will be increased by 2.5 
mg.  
▪ Participants on Letrozole 2.5 this cycle will be increased to Letrozole 
5.0 in cycle 3. 
▪ Participants on Letrozole 5.0 this cycle will be increased to Letrozole 
7.5 in cycle 3. 
▪ The combination arm will continue to receive CC 50mg along with 
the increased letrozole dose. 
o If there is ovulation, treatment will be repeated in the next cycle with the 
same dose of letrozole. The combination arm will continue to receive CC 
50mg along with either Letrozole 2.5 or 5.0.  
• Schedule a follow up progesterone lab if necessary 
o Participants with anovulatory progesterone levels (<3 ng/ml) and evidence 
of follicular development will return for a repeat progesterone level 
assessment in 10-14 days (lab can be done locally or at clinic site). 

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o Participants with elevated anovulatory progesterone levels (1.5 < P4 < 3.0) 
and corpus luteum on ultrasound will return for a repeat progesterone level 
assessment in 2-3 days  
• Dispense pregnancy test and medication for next cycle and review instructions for 
medication 
o Participants without ovulation nor evidence of follicular development are to 
complete pregnancy test and begin medication at new dose immediately 
following negative pregnancy test 
o Participants with ovulation are to wait until onset of menses, or two weeks 
after midluteal visit to complete pregnancy test. They can begin medication 
at same dose following negative pregnancy test. Participants with a positive 
pregnancy test will be moved to pregnancy track and will return dispensed 
medication at their next study visit.  
• Collect any unused medication from current (or previous) cycle and document 
participant compliance in RedCap 
• Record results of ultrasound and serum progesterone in RedCap 
Cycle 2 Follow-up Midluteal Visit* 
Participants with anovulatory progesterone levels (<3 ng/ml) and evidence of follicular 
development at their midluteal visit will return for a repeat progesterone level 
assessment in 10-14 days. This can be performed at a local lab if the participant 
prefers. 
• Serum progesterone assessment for ovulation 
• Review subject calendar log and record adverse events as reported by subject or 
observed by investigator. 
• Review instructions for previously dispensed medication 
o Participants without ovulation are to complete pregnancy test and begin 
medication at new dose immediately following negative pregnancy test 
o Participants with ovulation are to wait until onset of menses, or two weeks 
after midluteal visit to complete pregnancy test. They can begin medication 
at new dose (if ovulation did not occur on or before cycle day 21)  following 
negative pregnancy test. Participants with a positive pregnancy test will be 
moved to pregnancy track and will return dispensed medication at their next 
study visit.  

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▪ Participants who were initially anovulatory at a study visit prior to 
cycle day 21, who are ovulatory at a follow up visit by cycle day 21 
will be maintained on the same dose of medication. This may occur 
if participant’s study visit was moved up due to an early false positive 
ovulation prediction test. 
o  
• Record results of serum progesterone in RedCap 
Cycle 2 Menses Check-In/Cycle 3 Start (menses following Cycle 2)*  
Two weeks post Midleuteal visit if no menses before then 
Participants with ovulation are to wait until onset of menses, or two weeks after 
midluteal visit to complete pregnancy test. They can begin medication at new dose 
following negative pregnancy test. This visit can be completed remotely with 
participant logging information in RedCap. Participants with a positive pregnancy 
test will be moved to pregnancy track and will return dispensed medication at their 
next study visit.  
Cycle 3 Midluteal Visit  
Timing will be based on LH testing, ideally around 7-8 days post-positive test or 
CD21-24 if no positive test. 
• Transvaginal ultrasound to assess for corpora lutea and endometrial thickness and 
pattern 
• Serum progesterone assessment for ovulation 
• Review subject calendar log and record adverse events as reported by subject or 
observed by investigator. 
• Schedule a follow up ultrasound if necessary 
o Participants with anovulatory progesterone levels (<3 ng/ml) and evidence 
of follicular development will return for a repeat progesterone level 
assessment in 10-14 days. 
• Dispense pregnancy test review instructions for study completion 
o Participants with ovulation are to wait until onset of menses, or two weeks 
after midluteal visit to complete pregnancy test. Participants with a positive 
pregnancy test will be moved to pregnancy track.  

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• Collect any unused medication from current or previous cycles and document 
participant compliance in RedCap 
• Record results of ultrasound and serum progesterone in RedCap 
Cycle 3 Follow-up Midluteal Visit*  
Participants with anovulatory progesterone levels (<3 ng/ml) and evidence of follicular 
development at their midluteal visit will return for a repeat progesterone level 
assessment in 10-14 days. This can be performed at a local lab if the participant 
prefers. 
• Serum progesterone assessment for ovulation 
• Schedule a follow up Progesterone lab if necessary 
o Participants with anovulatory progesterone levels (<3 ng/ml) and evidence 
of follicular development will return for a repeat progesterone level 
assessment in 10-14 days. 
o Participants with elevated anovulatory progesterone levels (1.5 < P4 < 3.0) 
and corpus luteum on ultrasound will return for a repeat progesterone level 
assessment in 2-3 days  
• Review subject calendar log and record adverse events as reported by subject or 
observed by investigator. 
• Review instructions for study completion 
o Participants with ovulation are to wait until onset of menses, or two weeks 
after midluteal visit to complete pregnancy test. Participants with a positive 
pregnancy test will be moved to pregnancy track.  
Record results of serum progesterone in RedCap 
7.4 
Pregnancy Track Visits (part of routine care obstetrical care) 
Patients who report a positive urine pregnancy test will have a serum hCG to confirm 
pregnancy, with a follow up serum hCG 48-72 hours after initial hCG. Results from 
patients’ viability ultrasound will be obtained through chart abstraction. Patients with 
ongoing pregnancies will be followed through postpartum with 3 remote visits. Patients 
who experience biochemical pregnancy or 1st trimester pregnancy loss in pregnancies 
resulting from their 1st or 2nd treatment cycle may return to the treatment track and begin 
their next treatment cycle after one normal menses and a negative pregnancy test. 
Pregnancy Lab Visit 

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Participants with positive urine pregnancy test will have pregnancy confirmed with 
serum hCG assessment. This can be performed at a local lab if the participant prefers. 
• Serum hCG assessment for pregnancy 
• Review subject calendar log and record adverse events as reported by subject or 
observed by investigator. 
• Review instructions for pregnancy follow up, return to treatment track, or end of 
study as necessary 
• Review plans for pregnancy care and obtain consent for obtaining information if 
pregnancy provider records will need to be requested and consent to obtain 
medical information on file is not up to date 
• Collect any unused medication from current or previous cycle(s) and document 
participant compliance in RedCap 
• Record results in RedCap 
Pregnancy Lab Visit 2 
Pregnant participants will have a repeat serum hCG assessment 48-72 hours after 
initial hCG. This can be performed at a local lab if the participant prefers. 
• Serum hCG assessment  
• Review instructions for pregnancy follow up, return to treatment track, or end of 
study as necessary 
• Review plans for pregnancy care and obtain consent for obtaining information if 
pregnancy provider records will need to be requested and consent to obtain 
medical information on file is not up to date 
• Record results in RedCap 
Ongoing Pregnancy Follow up 
Approximately 3 weeks after positive pregnancy test. 
• Obtain viability ultrasound and enter results in RedCap 
• Review instructions for pregnancy follow up, return to treatment track, or end of 
study as necessary 
• Review plans for pregnancy care and obtain consent for obtaining information if 
pregnancy provider records will need to be requested and consent to obtain 
medical information on file is not up to date 

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12-15 Week Pregnancy Follow up 
• Review records (if available) to determine if participant has experienced a loss. 
• Participant will complete 12-15 week pregnancy follow up questionnaire via online 
surveys or phone. 
• Review instructions for pregnancy follow up, return to treatment track, or end of 
study as necessary 
• Review plans for pregnancy care and obtain consent for obtaining information if 
pregnancy provider records will need to be requested and consent to obtain 
medical information on file is not up to date 
• Record abstraction details or participant responses in RedCap 
Postpartum Pregnancy Follow up 
• Review records (if available) to determine outcome of pregnancy. 
• Participant will complete postpartum pregnancy follow up questionnaire via online 
surveys or phone. 
• Review instructions for return to treatment track or end of study as necessary 
• Review pregnancy care received and delivery and obtain consent(s) for obtaining 
information for mother if pregnancy provider records will need to be requested and 
consent to obtain medical information on file does not include named providers 
• Obtain consent(s) for obtaining information for infant(s) if delivery records will need 
to be requested  
• Record infant date of birth, birth weight and length, and any birth defects noted by 
the pediatrician or mother in RedCap. This information can be obtained from 
mother the RedCap Postpartum survey.   
• Have participant complete questionnaires (GAD7, PHQ9, FertiQoL, and Perceived 
Stress Scale, or if participant prefers to complete online, provide instructions on 
completing forms after visit 
 
7.5 
Final Study Visit/Cycle 3 Menses check in 
An end of treatment visit or phone call will occur after menses occurs with a negative 
pregnancy test or negative pregnancy test in the case of an anovulatory treatment cycle 
or following a positive pregnancy test.  This visit will be held within 1 week of outcome 
(negative or positive pregnancy test) Any unused study medication will be returned to the 

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study team at this visit. Participants who completed paper journal logs will submit any 
remaining journal logs at this visit, and the end of treatment questionnaire will be 
completed.  
Final Study Visit  
• Record adverse events as reported by subject or observed by investigator. 
• Record results of home urine pregnancy test and subsequent serum hCG tests. 
• Review subject calendar log and record adverse events as reported by subject or 
observed by investigator. 
• Collect any unused study medication and document participant compliance in 
RedCap 
• Complete end of treatment questionnaire with subjects if they have not completed 
online 
• Complete post questionnaires (PHQ9, GAD7, and Perceived Stress Scale) with 
participant if they have not completed online 
• Provide final instructions to subject  
7.6 
Missed Study visits 
In the event a subject is unable to complete their midluteal ultrasound, progesterone 
lab, or follow up progesterone lab, ovulation will be assessed by presence and timing of 
spontaneous menses. 
Subjects can postpone a cycle if they know that they will not be able to complete 
midluteal visit components within the projected window, taking a cycle off between study 
cycles. Timing of cycles will be captured in RedCap. However, in the event of 
unexpected inability to attend, as may occur if a subject were to contract a COVID-19 
infection during their study cycle, menses can be used as an indication of ovulation in 
place of progesterone lab and ultrasound results. 

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8 STUDY PROCEDURES /EVALUATIONS 
8.1 
Study Procedures/Evaluations 
• Medical history will be assessed by chart abstraction and confirmation with the 
patient at the Screening or Enrollment visit.   
• Physical examination will include chart abstraction of height and weight and BMI 
and if not in chart will be performed at screening visit.  
• Participants will be asked about hirsutism symptoms.  
• Transvaginal ultrasound of uterus and ovaries will be performed to obtain the 
following measures: endometrial thickness and evaluation for presence of corpora 
lutea and number of corpora lutea.  
• Urine pregnancy tests 
• Participant Journal Logs will be used to track medication adherence, side effects, 
intercourse, and concomitant medications 
 
Standard Clinical care: 
• Transvaginal ultrasound will also be performed at the ongoing pregnancy visit to 
record the number of gestational sacs, measurement of gestational sac(s), yolk 
sac(s), crown rump length, presence of fetal heart motion and rate and any 
abnormalities.   
• Assessment of tubal factor and uterine cavity by saline sonohystogram, 
hysterosalpingogram, or laparoscopy if recommended by provider however not 
required to participate in the study 
• Semen analysis of male partner to rule out male factor 
8.2 
Medical record review will be performed for labs, including: TSH, prolactin, 
HbgA1c, 17-OH Progesterone, AMH, Rubella, FSH and estradiol, Total 
testosterone and SHBG; progesterone documenting anovulation. All of these labs 
are not required for participation but if they have been done should be 
documented.  Documentation of TSH, HbgA1c and Rubella status recommended 
for participation.  These will be entered into RedCap.   
8.2.1 
Clinical Laboratory Evaluations performed at local labs 
• Progesterone will be assessed at the local lab to determine treatment plan 
for next cycle and ovulatory status 
• Urine hCG will performed by the patient 

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• Serum hCG if indicated will be assessed at the local lab to confirm 
pregnancy status if positive urine hCG (standard clinical care) 

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9 ASSESSMENT OF SAFETY 
9.1 
Specification of Safety Parameters 
9.1.1 
Adverse Events 
An adverse event is any untoward or unfavorable medical occurrence in a human subject, 
including any abnormal sign (for example, abnormal physical exam or laboratory finding), 
symptom, or disease, temporally associated with the subject’s participation in the 
research, whether or not considered related to the subject’s participation in the research. 
9.1.2 
Serious Adverse Events 
SAEs are a subset of all AEs. A serious adverse event (SAE) is one that meets one or 
more of the following criteria: 
• Results in death 
• Is life-threatening (places the subject at immediate risk of death from the event as 
it occurred) 
• Results in inpatient hospitalization or prolongation of existing hospitalization 
• Results in a persistent or significant disability or incapacity 
• Results in a congenital anomaly or birth defect   
• An important medical event that may not result in death, be life threatening, or 
require hospitalization may be considered an SAE when, based upon appropriate 
medical judgment, the event may jeopardize the subject and may require medical 
or surgical intervention to prevent one of the outcomes listed in this definition. 
 
9.2 Time Period and Frequency for Event Assessment and Follow-Up 
 Unanticipated problems will be recorded in the data collection system throughout the 
study.  
The PI will record all reportable events with start dates occurring any time after informed 
consent is obtained until 7 (for non-serious AEs) or 30 days (for SAEs) after the last day 
of study participation.  At each study visit, the investigator will inquire about the 
occurrence of AE/SAEs since the last visit.  Events will be followed for outcome 
information until resolution or stabilization. 
9.3 Characteristics of an Adverse Event 

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9.3.1 
Relationship to Study Intervention 
The Medical Monitors and the Study PI will assess the relationship of all adverse events 
to study intervention or study participation as either related or not related. Evaluation of 
relatedness will consider etiologies such as natural history of the underlying disease, 
concurrent illness, concomitant therapy, study-related procedures, accidents, and other 
external factors.  
To assess relationship of an event to study intervention, the following guidelines will be 
used: 
1. Related (Possible, Probable, Definite) 
a. The event is known to occur with the study intervention. 
b. There is a temporal relationship between the intervention and event onset. 
c. The event abates when the intervention is discontinued. 
d. The event reappears upon a re-challenge with the intervention. 
2. Not Related (Unlikely, Not Related) 
a. There is no temporal relationship between the intervention and event onset. 
b. An alternate etiology has been established. 
9.3.2 
Expectedness of SAEs 
The Medical Monitors and the Study PI will be responsible for determining whether an 
SAE is expected or unexpected.  An adverse event will be considered unexpected if the 
nature, severity, or frequency of the event is not consistent with the risk information 
previously described for the intervention.   
9.3.3 
Severity of Event 
The following scale will be used to grade adverse events: 
1. Mild: no intervention required; no impact on activities of daily living (ADL) 
2. Moderate: minimal, local, or non-invasive intervention indicated; moderate impact 
on ADL 
3. Severe: significant symptoms requiring invasive intervention; subject needs major 
assistance with ADL 
9.4 
Reporting Procedures 
 

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Sites will report unanticipated problems (to subjects or others) in either the subjects 
REDCap record or via direct communication with the University of Iowa PI and study 
coordinator through email or phone call as needed. Alerts will be set up in REDCap, so that 
the University of Iowa study team is notified when an unanticipated problem is recorded. 
Unanticipated problems will be reported to the IRB per institution reporting guidelines. 
 
Adverse Events and Serious Adverse Events will be recorded in RedCAP, entry of Serious 
Adverse Events will trigger email notification to the PI and the study coordinator. Upon 
receipt of an adverse event alert, University of Iowa staff will follow up with the study site or 
subject who entered the data to trigger the alert to confirm accuracy. Data will be reported to 
the IRB of record and relying IRBs in accordance with institution policies. Additionally, 
reports of project safety data will be prepared for the safety monitors review twice annually. 
 
 
 
 

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10 STUDY OVERSIGHT 
In addition to the PI’s responsibility for oversight, study oversight will be under the 
direction of a safety monitors with expertise in Gynecology and in Reproductive 
Endocrinology and Infertility.   The safety monitors will review safety data every 6 months.  
If safety concerns arise, more frequent reviews may be conducted.   
Data reports will include side effect profiles and reports of any adverse events.  We will 
also provide data on any multiple gestations.   

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11 CLINICAL SITE MONITORING 
Throughout the study information and documents such as IRB approval memos, IRB 
approved materials, and study wide and site-specific amendments will be sent to relying 
sites via email and will be discussed with sites on monthly study conference calls. 
Information and documents from relying sites such as local context checklist, site 
delegation logs, changes in research personnel and information for continuing review 
will be sent to the University of Iowa study coordinator via email and may be discussed 
on monthly conference calls. 
 
All study data will be entered in REDCap by participating site staff. REDCap data quality 
functionality of field validation and queries will be used to identify and resolve 
discrepancies in data in real time. The REDCap report feature will be utilized by 
University of Iowa team to track completeness of data entry, any identified issues will be 
communicated to participating sites for confirmation and completion. REDCap provides 
a secure data entry platform which allows external collaborators to be added to projects, 
with data access groups to limit access to site specific records, while allowing all data to 
be entered into a single central project. 
 
Protocol deviations can be assessed through both cycle information entered in standard 
data entry fields in subjects REDCap files or in a specified field for protocol deviations. 
REDCap data quality features will be used to flag deviations from study protocol related 
to timeframe of study events, dosing of study medication, and missing expected 
protocol events. Site staff will be contacted regarding these deviations to confirm 
accuracy of data entry and to determine if a deviation occurred. In addition to these 
fields, staff will be able to enter additional information on protocol deviations in a specific 
field in the subjects REDCap file. Data entered in this field will generate an alert to 
University of Iowa Study staff to review the deviation. 
 
Any concerns about noncompliance at participating sites will be discussed with that 
site’s PI. University of Iowa PI and study coordinator may request to review participating 
cites study records, including consent documents, in the event of concerns related to 
non-compliance. In the event non-compliance is found/or found to be a reasonable 
concern, the University of Iowa PI or designee will report the issue to the IRB of record. 
To resolve issues of non-compliance, staff training may be provided via memos or via 
conference call. Should retraining efforts not provide satisfactory resolution to 
noncompliance and/or violation of the contract/protocol, the site’s participation in the 
study may be terminated.  
 
11.1 

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12 STATISTICAL CONSIDERATIONS/DATA ANALYSIS 
12.1 
Justification of Effect Size 
12.1.1 Prior Studies  
 
Strong data on the per cycle cumulative ovulation with letrozole is available from the 
PPCOS II study.   Unfortunately, there are not comparative quality data from 
randomized trials of the combination of letrozole and clomiphene citrate (CC), as 
discussed in the background section. The cumulative live birth proportion for subjects 
randomized to receive letrozole was 0.275 for the five-treatment cycle study period.  
 
Per Cycle Ovulation and Live Birth Results in Letrozole arm of the PPCOS II study 
 
 
Ovulations/subject 
Pre-treatment cycle 1 
4/14 (28.6%) 
Treatment cycle 1 
178/360 (49.4%) 
Treatment cycle 2 
204/318 (64.2%) 
Treatment cycle 3 
179/268 (66.8%) 
 
12.1.2 Minimum Clinically important differences 
Considering the cumulative ovulation rates over 3 cycles from PPCOS II, data from our 
initial pilot study, as well as a clinically relevant increase in ovulation, we designed the 
study with 80% power to detect a 20% increase in ovulation rate among women treated 
with letrozole combined with CC, compared to those treated with letrozole 
monotherapy.  We believe this method balances the risk of avoiding a type 2 error and 
along with an attainable sample size.   
 
12.1.3 Significance Testing 
Primary statistical analyses will invoke the intent-to-treat approach. Primary efficacy 
analysis will be performed by comparing the treatment groups with respect to the 
primary outcome of ovulation using Pearson chi-square test. Additional analysis will be 
performed using logistic regression modeling to adjust for other factors if needed such 
as the randomization stratification of study site, prior exposure to study medications, 
age and BMI. Summary descriptive statistics including mean, standard deviation, 
number of observations and quartiles will be provided for continuous variables; while 
frequencies and percentages will be provided for categorical variables. All hypothesis 
tests will be two-sided and all analyses will be performed using SPSS or SAS statistical 
software. 

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12.1.4 Sample Size Calculations 
Considering the cumulative ovulation rate over 3 cycles from PPCOS II, data from 
our initial pilot study, and a clinically relevant increase in ovulation, we designed the 
study with 80% power to detect a 20% absolute difference in ovulation rate among 
women treated with letrozole combined with CC, compared to those treated with 
letrozole monotherapy. Allowing 10% dropout following randomization requires 92 
patients per arm, or 184 total. Allowing for an additional 15-20% screening failure 
rate requires 220 consented to reach our randomization goal.  
 
 
12.2 
Statistical Analysis 
 
All analyses will utilize the intention-to-treat (ITT) principle. All statistical tests of 
hypotheses will be two-sided. Baseline characteristics will be summarized by 
treatment arm. The primary outcome, cumulative ovulation, will be analyzed by 
comparing proportions utilizing a chi square test with significance set at 0.05. 
Dichotomous secondary outcomes will be analyzed in the same manner as the 
primary outcome. Two-sided t-tests will be used to compare endometrial lining 
thickness. Wilcoxon-Mann-Whitney tests will be used to compare number of corpora 
lutea. Time to pregnancy will be analyzed as a continuous variable using Kaplan-
Meier survival analysis. Per-protocol analyses will be conducted to provide additional 
insight. 
 
12.3 
Secondary Analyses  
12.3.1 Descriptive Summary 
We propose a number of secondary analyses, including assessing differences in 
conception and clinical pregnancy rates, live birth rates and multiple pregnancy 
rates, pregnancy loss rates (biochemical, miscarriage, ectopic), time to pregnancy, 
ultrasound measures (number of corpora lutea, endometrial thickness and pattern 
by ultrasound) and obstetric outcomes of pregnancy complication rate, birth weight, 
and neonatal complication rate.  We will also evaluate side effect profile of both 
groups and compare % percentage of patients that would not take study treatment 
due to side effects.   
12.3.2 Statistical Analyses  
12.3.3 Other Secondary Analyses 
Generalized estimating equations will be used as appropriate for secondary 
analyses of differences in means and binary outcomes where the main independent 
variables will be treatment group, time, and their interaction, in order to account for 

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within-subject variability in repeated observations over time. Potential covariates in 
the models include recruitment site, prior exposure to the medication, use of insulin 
sensitizers (metformin), baseline value of the outcome, and age.  
Cox proportional hazards models and Kaplan-Meier method will be used to 
compare the time to pregnancy between groups. 
In addition to the primary intent-to-treat analysis, a per protocol analysis will be 
performed as a secondary analysis. 
12.3.4 Sub study Analyses 
In our sub study analyses we will compare the differences in corpora luteal number 
and endometrial thickness between the two arms of the study. Previously reported 
ultrasound parameters for Letrozole are presented in the table below.  
Mean and standard deviation ultrasound parameter assumptions for letrozole 
treatment group  
Endometrial 
Thickness (mm) 
6.2 ± 2.2 in 
Letrozole group 
 
8.3 ± 3.6 in Combo 
group 
Mejia et al, 2018  
34 cycles of 
letrozole 2.5 and  
33 cycles of 
combo (letrozole 
2.5 + CC 50) in 
women with 
PCOS on cycle 
day 12-14 
Number of follicles > 
10 mm 
0.4 ± 0.56 in 
Letrozole group 
 
2.0 ± 2.13 in Combo 
group 
Mejia et al, 2018 
34 cycles of 
letrozole 2.5 and  
33 cycles of 
combo (letrozole 
2.5 + CC 50) in 
women with 
PCOS on cycle 
day 12-14 
Largest follicle size 
(mm) 
11.71 ± 4.50 in 
Letrozole group 
 
15.61 ± 5.9 in 
Combo group 
Mejia et al, 2018  
34 cycles of 
letrozole 2.5 and  
33 cycles of 
combo (letrozole 
2.5 + CC 50) in 
women with 
PCOS on cycle 
day 12-14 

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An additional sub study analysis will report subsequent fertility treatments and 
outcomes in patients who do not have an ongoing pregnancy at the conclusion of 
participation. The follow up window for these participants will be 10 months. 
12.3.5 Sample size calculation 
 
Considering midluteal endometrial thickness previously reported in ovulatory 
letrozole treatment cycles and hypothesized ovulation rates, the planned sample of 
184 patients will have 94% power to detect a .25mm difference in midluteal 
endometrial thickness between the two arms among patients who ovulate. 
Assuming follicles >15mm on CD 12-14 in our preliminary study are indicative of 
corpora lutea, the planned sample will have 90% power to detect a 0.3 difference in 
mean number of corpora lutea among patients who ovulate.  
12.4 
Missing Data 
Every attempt will be made to obtain the full set of outcome values for each 
participant. Despite this effort, we expect there will be some missing data due to 
dropouts and missed visits. Missing data for binary outcomes will be calculated with 
both conservative (assumed negative (e.g. no ovulation) and liberal with assumed 
yes ovulation unless later data contradicts this.  If necessary, imputation will be 
used.   
12.5 
Adverse Event Analysis 
Adverse events will be categorized and frequency and percentage of patients 
experiencing adverse events and serious adverse events during the study period will be 
reported. Chi-square tests will be utilized to compare differences in proportion of total 
and categories of adverse events within each treatment arm. 
12.6 
Interim Analysis 
We propose not to perform an interim analysis.  Both the small sample size and 
relatively low risk of multiple gestation we do not see that an interim analysis is 
necessary.   
 

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13 ETHICS/PROTECTION OF HUMAN SUBJECTS 
13.1 
Ethical Standard 
The investigator will ensure that this study is conducted in full conformity with the 
principles set forth in The Belmont Report: Ethical Principles and Guidelines for the 
Protection of Human Subjects of Research, as drafted by the US National Commission 
for the Protection of Human Subjects of Biomedical and Behavioral Research (April 18, 
1979) and codified in 45 CFR Part 46 and/or the ICH E6.  
13.2 
Institutional Review Board 
The protocol, informed consent form(s), recruitment materials, and all subject materials 
will be submitted to the IRB for review and approval.  Any amendment to the protocol will 
require review and approval by the IRB before the changes are implemented in the study 
and then the Protocol document will be updated accordingly.   
The University of Iowa will serve as the single IRB for this multi-site trial.   
13.3 
Informed Consent Process 
Informed consent is a process that is initiated prior to the individual agreeing to participate 
in the study and continues throughout study participation.  Extensive discussion of risks 
and possible benefits of study participation will be provided to subjects and their families, 
if applicable.  A consent form describing in detail the study procedures and risks will be 
given to the subject.  Consent forms will be IRB-approved, and the subject is required to 
read and review the document or have the document read to him or her.  The investigator 
or designee will explain the research study to the subject and answer any questions that 
may arise.  The subject will sign the informed consent document prior to any study-related 
assessments or procedures.  Subjects will be given the opportunity to discuss the study 
with their surrogates or think about it prior to agreeing to participate.  They may withdraw 
consent at any time throughout the course of the study.  A copy of the signed informed 
consent document will be given to subjects for their records.  The rights and welfare of 
the subjects will be protected by emphasizing to them that the quality of their clinical care 
will not be adversely affected if they decline to participate in this study. 
The consent process will be documented in the clinical or research record. Different 
versions of the informed consent documents may be used across sites to comply with 
local IRB policies. Apart from policy required modifications, all sites will use informed 
consent documents with the same content.    
13.4 
Subject Confidentiality 
Subject confidentiality is strictly held in trust by the investigators and study staff.  This 
confidentiality is extended to cover testing of biological samples in addition to any study 
information relating to subjects. 

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The study protocol, documentation, data, and all other information generated will be held 
in strict confidence.  No information concerning the study or the data will be released to 
any unauthorized third party without prior written approval of the PI. 
The study monitor or other authorized representatives of the sponsor may inspect all 
study documents and records required to be maintained by the investigator, including but 
not limited to, medical records (office, clinic, or hospital) for the study subjects.  The 
clinical study site will permit access to such records. 
13.5 
Study Intervention Compliance 
 
This section describes the strategy, responsibilities, and quality management activities in 
place to demonstrate that there is adequate monitoring of the clinical trial by the Principal 
Investigator (PI) to ensure:  
• 
The trial is conducted according to the investigational plan, protocol and applicable laws, 
regulations, policies and guidance 
• 
The rights, welfare, and safety of human subjects are protected 
• 
Proper reporting of study data to the FDA and IRB 
• 
The PI is providing adequate oversight of the clinical trial 
 
The plan includes both internal quality and external, independent safety management 
processes used throughout the study, including but not limited to staff training, standardized 
procedures, methods for data collection, study and data monitoring, and routine team 
meetings to review the study progress and isolate any compliance issues and/or trends. 
13.5.1 Study Team Training 
 
Members of the study team are trained on the protocol and/or study procedures 
applicable to their roles and responsibilities. When the protocol and/or study procedures 
are updated, staff will be trained on the revisions prior to implementation, as applicable. 
Training is documented and maintained in the study files. 
 
13.5.2 Investigator/Study Team Member Agreement 
All members of the study team are informed of their responsibilities specific to their 
role(s) in this study, their obligation to follow the approved clinical research protocol, the 
applicable regulations, guidelines and institutional policies. Documentation of this 
agreement is maintained in the study files following site specific policies. 
 
13.5.3 Financial Disclosure 
Financial disclosure information is collected for all members of the study team that make 
a direct and significant contribution to the data. Financial disclosure documentation is 
maintained following site specific policies.  
 

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13.5.4 Routine Study Team Meetings 
Routine study team meetings ensure on-going supervision and oversight of the study 
and study personnel involved in the conduct of the study. In the meetings, the principal 
investigator (PI) and study team members discuss evaluations of study-related activities 
(as applicable): identification of deviations or noncompliance, review of adverse events, 
and overall study progress. Training on protocol, procedure and/or form updates may 
also be performed during routine meetings.  
 
 
 

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14 DATA HANDLING AND RECORD KEEPING 
All study data will be entered in REDCap by participating site staff. REDCap data quality 
functionality of field validation and queries will be used to identify and resolve 
discrepancies in data in real time. The REDCap report feature will be utilized by 
University of Iowa team to track completeness of data entry, any identified issues will be 
communicated to participating sites for confirmation and completion. REDCap provides 
a secure data entry platform which allows external collaborators to be added to projects, 
with data access groups to limit access to site specific records, while allowing all data to 
be entered into a single central project. 
 
While most data will be directly entered into RECap, sites are expected to retain subject 
informed consent documents and other source documents when they exist. Clinical data 
(including AEs, laboratory values, ultrasound results, and solicited events data) and 
clinical laboratory data will be abstracted from the patient’s electronic medical record 
(EMR) and entered into REDCap. The investigators are responsible for ensuring the 
accuracy, completeness, legibility, and timeliness of the data reported.  All source 
documents should be completed in a neat, legible manner to ensure accurate 
interpretation of data.  The investigators will maintain adequate case histories of study 
subjects, including accurate case report forms (CRFs), and source documentation. 
Study consent documents will be maintained for at least ten years from the date that the 
project is closed in the IRB, or longer as needed to comply with local IRB record retention 
policies. Other study records will be retained in RedCap through completion of collection 
and data cleaning of live birth and other delivery/infant outcomes for all participants in the 
project. After data are cleaned, de-identified data will be downloaded and stored for 
analyses and publications. 
 

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15 PUBLICATION/DATA SHARING POLICY 
Publication and authorship procedures will be established and agreed upon by all 
investigators.   

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16 LITERATURE REFERENCES 
BIBLIOGRAPHY 
1. 
(CDC) CfDCaP. National Public Health Action Plan for the Detection, Prevention, and Managment 
of Infertility. In: Prevention CfDCa, ed. Atlanta (GA), 2014. 
2. 
Hamilton-Fairley D, Taylor A. Anovulation. BMJ (Clinical research ed) 2003;327:546-9. 
3. 
Teede HJ, Misso ML, Costello MF, Dokras A, Laven J, Moran L et al. Recommendations from the 
international evidence-based guideline for the assessment and management of polycystic ovary 
syndrome. Fertility and sterility 2018;110:364-79. 
4. 
Legro RS, Brzyski RG, Diamond MP, Coutifaris C, Schlaff WD, Casson P et al. Letrozole versus 
clomiphene for infertility in the polycystic ovary syndrome. The New England journal of medicine 
2014;371:119-29. 
5. 
Eijkemans MJ, Imani B, Mulders AG, Habbema JD, Fauser BC. High singleton live birth rate 
following classical ovulation induction in normogonadotrophic anovulatory infertility (WHO 2). Human 
reproduction (Oxford, England) 2003;18:2357-62. 
6. 
Sunderam S, Kissin DM, Crawford SB, Folger SG, Boulet SL, Warner L et al. Assisted Reproductive 
Technology Surveillance - United States, 2015. Morbidity and mortality weekly report Surveillance 
summaries (Washington, DC : 2002) 2018;67:1-28. 
7. 
Woo I, Hindoyan R, Landay M, Ho J, Ingles SA, McGinnis LK et al. Perinatal outcomes after 
natural conception versus in vitro fertilization (IVF) in gestational surrogates: a model to evaluate IVF 
treatment versus maternal effects. Fertility and sterility 2017;108:993-8. 
8. 
Cavoretto P, Candiani M, Giorgione V, Inversetti A, Abu-Saba MM, Tiberio F et al. Risk of 
spontaneous preterm birth in singleton pregnancies conceived after IVF/ICSI treatment: meta-analysis of 
cohort studies. Ultrasound in obstetrics & gynecology : the official journal of the International Society of 
Ultrasound in Obstetrics and Gynecology 2018;51:43-53. 
9. 
Peeraer K, Luyten J, Tomassetti C, Verschueren S, Spiessens C, Tanghe A et al. Cost-effectiveness 
of ovarian stimulation with gonadotrophin and clomiphene citrate in an intrauterine insemination 
programme for subfertile couples. Reproductive biomedicine online 2018;36:302-10. 
10. 
Wu AK, Odisho AY, Washington SL, 3rd, Katz PP, Smith JF. Out-of-pocket fertility patient 
expense: data from a multicenter prospective infertility cohort. The Journal of urology 2014;191:427-32. 
11. 
Clark JH, Markaverich BM. The agonistic-antagonistic properties of clomiphene: a review. 
Pharmacology & therapeutics 1981;15:467-519. 
12. 
Palomba S. Aromatase inhibitors for ovulation induction. The Journal of clinical endocrinology 
and metabolism 2015;100:1742-7. 
13. 
Giudice LC. Insulin-like growth factors and ovarian follicular development. Endocrine reviews 
1992;13:641-69. 
14. 
Adashi EY. Intraovarian regulation: the proposed role of insulin-like growth factors. Annals of the 
New York Academy of Sciences 1993;687:10-2. 
15. 
Vendola K, Zhou J, Wang J, Famuyiwa OA, Bievre M, Bondy CA. Androgens promote oocyte 
insulin-like growth factor I expression and initiation of follicle development in the primate ovary. Biology 
of reproduction 1999;61:353-7. 
16. 
Weil S, Vendola K, Zhou J, Bondy CA. Androgen and follicle-stimulating hormone interactions in 
primate ovarian follicle development. The Journal of clinical endocrinology and metabolism 
1999;84:2951-6. 

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17. 
Mejia RB, Summers KM, Kresowik JD, Van Voorhis BJ. A randomized controlled trial of 
combination letrozole and clomiphene citrate or letrozole alone for ovulation induction in women with 
polycystic ovary syndrome. Fertility and sterility 2018;In press. 
18. 
Hajishafiha M, Dehghan M, Kiarang N, Sadegh-Asadi N, Shayegh SN, Ghasemi-Rad M. Combined 
letrozole and clomiphene versus letrozole and clomiphene alone in infertile patients with polycystic 
ovary syndrome. Drug design, development and therapy 2013;7:1427-31. 
19. 
W V, K H. Letrozole versus Clomiphene in PCOS -more than one way to crack an egg. Fertility and 
sterility 2019;111:469. 
20. 
Medicine. PCotASfR. Definitions of infertility and recurrent pregnancy loss: a committee opinion. 
Fertility and sterility 2013;99:63. 
 
 

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APPENDICES 
 
Appendix A: Schedule of Events

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APPENDIX A: SCHEDULE OF EVENTS 
 
 
 
Treatment visits (Repeat for up to 3 treatment cycles) 
Pregnancy Follow up 
 
Screening 
Period 
 
Baseline 
Visit  
Monthly 
Midlueteal 
visit  
Follow up 
Midluteal 
visit*  
Menses 
check in 
appointment  
End of 
Treatment 
follow-up  
Pregnancy 
lab visit 
Ongoing 
pregnancy 
follow up 
12-15 
week 
f/u 
Postpartum 
f/u 
Assessments 
 
Cycle day 
1-3 (+2), 
random 
start 
18 -26 days 
post 
medication 
start 
10-14 days 
after 
midlueteal 
visit  
Onset of 
menses or 2 
weeks after 
midluteal 
visit 
After completion 
of 3rd treatment 
cycle or 
following 
pregnancy 
48-72 hrs 
after initial 
hCG 
~3 weeks 
after positive 
pregnancy 
test 
 
 
Pre- Screening questionnaire 
Xc 
 
 
 
 
 
 
 
 
 
Informed consent 
X c 
 
 
 
 
 
 
 
 
 
Confirm Inclusion/Exclusion 
criteria 
X 
 
 
 
 
 
 
 
 
 
Abstract Demographics, 
medical history 
X 
 
 
 
 
 
 
 
 
 
Abstract physical exam 
(Anthropometrics, hirsutisum 
assessment) Vital signs & 
weight 
X 
 
 
 
 
 
 
 
 
 
Transvaginal ultrasound 
(abstract) 
 
X 
 
 
 
 
 (abstract) 
 
 
Randomization 
 
X 
 
 
 
 
 
 
 
 
Inclusion laboratory testinga 
(abstract) 
 
 
 
 
 
 
 
 
 
Dispense Meds 
 
X 
X 
 
X 
 
 
 
 
 
Serum Progesteronea 
 
 
X 
X 
 
 
 
 
 
 
Serum hCGa 
 
 
 
 
 
 
X 
 
 
 
Biospecimen collection, 
bloodb:  
 
 
 
 
 
 
 
 
 
 
Urine pregnancy test 
 
X (1st) 
 
 
Xc 
Xc 
 
 
 
 

CLC II Protocol Manual 
Protocol Version 1.2 
IRB# 201906826 
9-27-2021 
 ________________________________________________________________________________________________________  
 
 ____________________________________________________________________________________________ 
Based on NIDCR Clinical Trial (Interventional) Protocol Template v4.0 - 20140103 
64 
 
Assessment of other 
infertility factors: tubal factor 
and uterine cavity, male 
factor 
(abstract) 
 
 
 
 
 
 
 
 
 
Journal Log 
 
Throughout Treatment Follow upc 
 
Xc 
Xc 
 
 
AE query 
 
 
Throughout Follow upc 
 
 
Follow up questionnaire 
 
 
 
 
 
x 
 
 
Xc 
Xc 
Follow up chart abstraction 
 
 
 
 
 
 
 
 
X 
X 
 
Screening can be done on the same day as the baseline visit. 
*If Anovulatory progesterone level < 3 ng/mL and evidence of follicular development 
aTesting to be performed at local lab 
b Samples to be sent to central laboratory for biobanking and future testing; if consented for biobank 
c Component may be completed via RedCap or phone, can be completed by Iowa staff 
 
 

CLC II Protocol Manual 
Protocol Version 1.2 
IRB# 201906826 
9-27-2021 
 ________________________________________________________________________________________________________  
 
 ____________________________________________________________________________________________ 
Based on NIDCR Clinical Trial (Interventional) Protocol Template v4.0 - 20140103 
65 
 
Tool Revision History: 
 
Version  Number Version Date 
Summary of Revisions Made: 
 
 
Original version with Tool Summary Sheet 
 
 
Revised text regarding Safety Oversight method, Final 
Statistical Analysis, Data Sharing, and Clinical Site 
Monitoring; clarified instructional text and added text 
placeholders