Conditions: Polycystic Ovary Syndrome Infertility
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 70
Healthy volunteers: no

Brief summary:
This study evaluates the addition of clomid to letrozole for the treatment of infertility in women with polycystic ovary syndrome. Half of the participants will receive letrozole and clomid in combination, while the other half will receive letrozole alone.

Detailed description:
Letrozole and Clomid are both used for ovulation induction, but they have different mechanisms of action. Letrozole has been shown to be superior to clomid in achieving live birth rates in women with infertility and polycystic ovary syndrome. However, the combination of these medications has not been studied. This is a pilot study to evaluate if the combination treatment has improved efficacy as measured by ovulation rate.

This is a randomized controlled trial of letrozole versus letrozole and clomiphene citrate (CC) for one menstrual cycle. Women will be randomized in a 1:1 ratio to receive letrozole 2.5 mg or combination of letrozole 2.5 mg and clomiphene 50 mg for 5 days on days 3-7 of menstrual cycle. The women and their partners will be instructed to have regular intercourse with the intent to conceive during the cycle. Patients will have an transvaginal ultrasound mid cycle and to evaluate number of follicles (\>15 mm), follicle size, endometrial thickness and pattern. Patients will have mid- luteal phase progesterone level drawn to evaluate ovulation. Side effect profile will also be monitored.

Arms:
arm 1: Letrozole 2.5 mg orally for 5 days on cycle days 3-7 arm 2: Letrozole 2.5 mg orally for 5 days on cycle days 3-7 AND Clomid 50 mg orally for 5 days on cycle days 3-7

Interventions: intervention 1: Clomiphene intervention 2: Letrozole
Intervention descriptions: intervention 1: None intervention 2: None

Protocol document:
Prot_SAP_000.pdf: 
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Combined Letrozole and Clomid in Polycystic 
Ovary Syndrome: A randomized control trial of 
combination of letrozole and clomiphene citrate 
or letrozole alone for the treatment of infertility in 
women with polycystic ovary syndrome 
 
Principal Investigators:  Rachel Mejia, DO and Brad Van Voorhis, MD 
Draft or Version Number:  2.0 
 
 
 
 
 
April 24, 2018


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TABLE OF CONTENTS 
PAGE 
TABLE OF CONTENTS .............................................................................................................. 2 
LIST OF ABBREVIATIONS ......................................................................................................... 3 
PROTOCOL SUMMARY ............................................................................................................. 4 
1 
KEY ROLES AND CONTACT INFORMATION ................................................................... 7 
2 
INTRODUCTION: BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE ......... 8 
2.1 
Background Information .......................................................................................... 8 
2.2 
Rationale ................................................................................................................ 9 
2.3 
Potential Risks and Benefits ................................................................................... 9 
2.3.1 
Potential Discomforts & Risks ..................................................................... 9 
2.3.2 
Potential Benefits ...................................................................................... 10 
3 
OBJECTIVES ................................................................................................................... 12 
3.1 
Primary research hypotheses ............................................................................... 12 
3.1.1 
Primary Outcome measures ...................................................................... 12 
3.2 
Secondary outcomes ............................................................................................ 12 
4 
STUDY DESIGN .............................................................................................................. 13 
4.1 
Study Summary .................................................................................................... 13 
4.2 
Study Population: .................................................................................................. 14 
5 
STUDY ENROLLMENT AND WITHDRAWAL .................................................................. 16 
5.1 
Subject Inclusion Criteria ...................................................................................... 16 
5.2 
Subject Exclusion Criteria ..................................................................................... 17 
6 
STATISTICAL CONSIDERATIONS .................................................................................. 18 
6.1 
Justification of effect size ...................................................................................... 18 
6.1.1 
Prior Studies.............................................................................................. 18 
6.1.2 
Minimum Clinically Important Difference .................................................... 18 
6.1.3 
Significance Testing .................................................................................. 18 
6.1.4 
Sample Size calculations........................................................................... 18 
7 
LITERATURE REFERENCES .......................................................................................... 20 
 


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LIST OF ABBREVIATIONS 
AE 
Adverse Event/Adverse Experience 
BMI 
Body Mass Index 
CC 
Clomiphene Citrate 
DHEA-S 
Dihydroepiandrosterone sulfate 
DHHS 
Department of Health and Human Services 
FDA 
Food and Drug Administration 
IRB 
Institutional Review Board 
IRL 
Iowa River Landing 
PCOS 
Polycystic Ovary Syndrome 
PPCOS II 
Pregnancy in Polycystic Ovary Syndrome Study II 
P4 
Progesterone 
PI 
Principal Investigator 
SAE 
Serious Adverse Event/Serious Adverse Experience 
UIHC 
University of Iowa Hospitals and Clinics 
US 
United States 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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PROTOCOL SUMMARY 
Title: 
Combined Letrozole and Clomid in Polycystic Ovary 
Syndrome: A randomized control trial of combination of 
letrozole and clomiphene citrate or letrozole alone for the 
treatment of infertility in women with polycystic ovary syndrome 
 
Précis: 
This will be a single center, randomized controlled open trial of 
letrozole versus letrozole and clomiphene citrate (CC) for one 
cycle.  Women will be randomized in a 1:1 ratio to receive 
letrozole 2.5 mg or combination of letrozole 2.5 mg and 
clomiphene 50 mg for 5 days on days 3-7 of menstrual cycle.  
We will stratify the randomization by age (< 35 versus >35) and 
BMI (<30, > 30) to try to ensure equal groups to study. The 
women and their partners will be instructed to have regular 
intercourse with the intent to conceive during the cycle.  
Patients will have an ultrasound on between cycle day 12 -14 
and will evaluate number of follicles (>15 mm), follicle size, 
endometrial thickness and pattern. Patients will have mid- 
luteal phase progesterone level drawn. The primary analysis 
will use an intent-to-treat approach to evaluate differences in 
ovulatory rate in the two treatment arms.  
 
Objectives: 
Primary:  Cumulative ovulation rate determined by a mid-luteal 
(day 21) phase progesterone level. Progesterone level > 3 
ng/mL will indicate ovulation.   
 
Secondary:  Size and number of developing follicles, 
endometrial thickness and pattern all determined by a mid-
cycle ultrasound. Positive pregnancy test, clinical pregnancy 
and ongoing pregnancy.  We will also report live birth rate, 
miscarriage rate, ectopic pregnancy rate and multiple 
pregnancy rate. We will also monitor complication rate and 
side effect profile of both treatment arms.    
Population: 
70 women with a diagnosis of polycystic ovary syndrome and 
infertility desiring to conceive. Participants will be 18-40 years 
of age.  
Phase: 
IV 
Number of Sites: 
1 – University of Iowa Hospitals and Clinics, Women’s Health 
Clinic and Quad Cities clinic 


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Description of  
Intervention: 
70 women will be equally randomized to two different treatment 
arms: A) letrozole 2.5 mg every day for 5 days (day 3-7 of 
cycle) or B) letrozole 2.5 mg and clomiphene citrate 50 mg 
every day for 5 days (3-7 of cycle), for one cycle.  
 
 
Subject 
Participation 
Duration: 
Approximately 5 weeks of active participation time.  Clinical 
chart abstraction and remote follow up will be continued for 10 
months following participation.  
Estimated Time to 
Complete 
Enrollment: 
18 months by enrolling ~3.89women per month 
 
 
 


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Study Diagram 
 
 
 
Screen and Consent 
Screen out 
Randomize 
Letrozole 2.5 mg 
  N = 34 
Letrozole 2.5 mg + 
Clomid 50 mg 
N=34 
Day 14 
ultrasound 
Mid luteal P4 
Ovulation 
P4 > 3 ng/mL 
Secondary outcomes 
No Ovulation 
P4 < 3 ng/mL 
Primary 
Outcome
Secondary outcomes 
Pregnant 
Secondary outcomes 


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1  KEY ROLES AND CONTACT INFORMATION 
Principal 
Investigator:   
Rachel Mejia, DO 
Fellow Associate, 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: 
<if applicable, investigator name, institution> 
Institutions: 
University of Iowa Hospitals and Clinics 
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 
 
 
 


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2 INTRODUCTION: BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE  
2.1 
Background Information 
 
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in 
reproductive age women and constitutes the most common cause of anovulatory infertility.1  The 
treatment of infertility in patients with PCOS focuses on ovulation induction.  Multiple treatment 
regimens have been used and all with varying success in regards to both ovulation and 
pregnancy rates.   
 
Clomiphene citrate (CC) is a commonly used pharmacologic agent to induce ovulation in 
women with PCOS. It works as a selective estrogen receptor modulator (SERM) by 
competitively attaching to nuclear estrogen receptors. As the negative feedback of estrogen is 
lowered it in turn activates increased secretion of gonadotropin hormones which subsequently 
causes ovarian follicular growth.  CC also has an antiestrogenic effect on endometrial 
development and cervical mucus production.  This has been implicated to contribute to the low 
pregnancy rate despite a relatively high ovulation rate.  2, 3 
Letrozole has a different mechanism of action and works as a highly selective aromatase 
inhibitor thus preventing androgen-to-estrogen conversion.  The negative feedback in the 
hypothalamus is decreased by the suppressed estrogen production which subsequently 
increases the concentration of follicle stimulating hormone (FSH).  An additional mechanism of 
aromatase inhibitors may result from increase follicular sensitivity to FSH resulting from 
temporary increased intraovarian androgens.4 Studies in primates have shown that testosterone 
augments follicular FSH receptor expression which supports the idea that androgens promote 
follicular growth. 5-7  Additionally, Garcia-Velasco et al demonstrated an increase in intraovarian 
androgen concentrations with the use of letrozole in low responder patients undergoing IVF.8   
Letrozole offers a benefit over CC for ovulation induction since it does not deplete estrogen 
receptors in both central and peripheral target tissues and normal central feedback mechanisms 
remain intact. Recently, a randomized control trial comparing letrozole to clomiphene 
demonstrated that letrozole was associated with higher live-birth rate (27.5% vs 19.1%, 
P=0.007, 95% CI 1.10 to 1.87) and cumulative ovulation rate (61.7% vs. 48.3%, P<0.001) 
among women with polycystic ovary syndrome.9  Despite the superior ovulatory and live birth 
rates with letrozole compared to CC the question remains if there are medical alternatives 
without proceeding to gonadotropins or IVF both of which are associated with increased costs 
and risks.   
 
Since letrozole and CC have different mechanisms of actions we postulate that the 
combination of these medications may offer a synergistic effect and improve the ovulatory rate.  
One study has prospectively reviewed treatment outcomes using a combination of letrozole and 
clomiphene who had previously failed CC for 6 cycles and letrozole for 4 cycles.  This study 
enrolled 100 patients and showed an ovulatory rate based on development of dominant follicle 
of 82.9% of cycles (213/257) with the combination treatment.10  However, this study was not 
randomized and used a limited population of women with PCOS that were resistant to both 
clomiphene and letrozole alone. Additionally, patients received Gonal-f on day 11 if a dominant 
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followed by IUI 36-38 hours later.  Despite the prospective observational nature of the study it 
does point to a potential improved ovulatory rate with this combination treatment.    
 
2.2 
Rationale 
 
Letrozole has been shown to have both higher live-birth and ovulation rates 
compared to CC among infertile PCOS women demonstrated by the PPCOS II trial. 
Despite the superior ovulatory and live birth rates with letrozole compared to CC the 
question remains if there are medical alternatives without proceeding to gonadotropins 
or IVF both of which are associated with increased costs and risks. One study has 
shown a potential benefit in combining letrozole and CC however a double blind trial is 
needed to test if this combination improves outcomes over letrozole alone.  
Mechanistically, the combination may have a synergistic action with letrozole having a 
local effect at the level of the ovary to block estrogen synthesis and with clomiphene 
having a central effect by antagonizing the negative feedback of estrogen at the 
hypothalamus by depleting estrogen receptors. These different mechanisms of actions 
may provide a synergistic effect to provide improved ovulation rates over use of 
letrozole alone. Since the combination of letrozole and clomiphene has not yet been 
studied in a prospective randomized fashion and it is unclear if this will offer an 
advantage over letrozole alone in terms of both ovulation and pregnancy rate, we have 
designed a pilot study to characterize the ovulatory rate with this combination treatment. 
It is necessary to first determine if the combination treatment is at least equivalent and 
possibly better than the standard efficacy of letrozole.  Prior to embarking on a larger 
trial to look at the most important outcome of live birth rate it is important to establish 
that this combination treatment does offer a superior ovulatory rate.   The aim of this 
study is to test the hypothesis that combined therapy of letrozole and CC is an effective 
and superior method to letrozole alone to achieve ovulation in women with PCOS.  
 
2.3 
Potential Risks and Benefits 
2.3.1 
Potential Discomforts & Risks 
Both letrozole and CC have 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.  
Test or Procedure 
Discomfort and Risks 


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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 and Letrozole is associated with a 3.4% multiple pregnancy rate 
in women with PCOS.  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%).9  
2.3.2 
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 and PCOS 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.  
With the mid-cycle ultrasound and hormone testing the participant may receive 
additional information and understanding related to their cause of infertility.   


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Possible benefits to others: The study will provide important information on the 
treatment for women with infertility and PCOS.  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 hypotheses  
Treatment with the combination of letrozole and clomiphene is more likely to result in 
ovulation (increased ovulation rate) compared to treatment with letrozole alone in 
women with infertility and PCOS.  
3.1.1 
Primary Outcome measures 
The primary outcome measure is the occurrence of ovulation defined as a mid-luteal 
progesterone level > 3 ng/mL. This will be tested 7 days following the patient reporting 
of an LH surge. If no LH surge is detected the lab will be drawn on cycle day 21 or 22.  
The primary analysis of ovulation rate within the two treatment conditions will employ an 
intent-to-treat approach.   
3.2 
Secondary outcomes 
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 and size of developing follicles 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.   


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4 STUDY DESIGN 
Treatment Design: This will be a single center, open trial of oral letrozole vs. 
combination of oral letrozole and clomiphene citrate in the treatment of infertility in 
patients with polycystic ovary syndrome.  Patients will be randomized to receive either a 
dose of 2.5 mg of letrozole or 2.5mg of letrozole and 50 mg of CC for 5 days on cycle 
days 3 through 7 of the menstrual cycle.  Patients will be monitored during the cycle 
with a mid-cycle ultrasound (cycle days 12-14) and a mid-luteal progesterone level 
(cycle day 21).  
The study will last for -1 cycles or approximately -5 weeks.  
Randomization will be stratified by age (< 35 versus > 35) and BMI (< 30 and > 30) to 
ensure equal groups to study.  Randomization will be via a computer based central 
randomization to ensure adequate allocation concealment.  
Enrollment will take approximately 18 months if ~ 3.89subjects are enrolled per month. 
Active subject participation will be through completion of -1 cycle.  We will follow up with 
patient regarding pregnancy, delivery outcomes, and if information is not available via 
chart abstraction.  
 
4.1 
Study Summary 
Initial visit: 
 
 
1. Study staff review pre-screening questionnaire and confirm eligibility criteria 
 
2. Obtain signed informed consent 
 
3. Confirm documentation of vital signs, height, weight and BMI. 
 
4. Record and review medical history 
 
5. Request subject to sign medical release form to obtain information regarding 
ongoing infertility treatment, pregnancy and delivery information.  
 
6. Complete urine pregnancy test or dispense urine pregnancy test to complete 
at a later date if participant plans on delaying treatment.   
 
  
 
7. Randomization to treatment group once negative pregnancy test.  
 
 


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- Orient and dispense calendar log which includes documentation of intercourse, 
menstrual log and side effect assessment  
 
- Dispense study medications 
Mid-cycle Visit (Visit #2): 
 
1.  Collect journal logs  
 
2.  Transvaginal ultrasound exam 
 
3. Return medication containers and study medications you did not take 
 
4. Dispense urine pregnancy test  
Mid-luteal lab draw (visit #3) 
 
1. Blood draw (P4) 
 
2. Schedule End of treatment visit 
 
 
 
 
End of Treatment Visit: 
 
1. Collect Calendar log 
 
2. If subject had a positive urine pregnancy test: blood draw will be performed 
and then repeated approximately 48 hours after the first one.  
 
3. Complete End of Treatment questionnaire   
 
4. Arrange for follow up and confirm we have a release of records for pregnancy 
and neonatal records.   
 
4.2 
Study Population:  
70 women with PCOS actively seeking pregnancy (or 35 per each treatment arm) aged 
> 18 to < 40 years will be enrolled.  The overall goal of enrollment criteria is to identify a 
population of healthy women with PCOS and infertility not specified by another cause. 
Infertility will be determined by clinical history. PCOS will be determined by Rotterdam 
criteria which includes two of three findings: oligo- or anovulation, hyperandrogenism or 
polycystic ovaries on ultrasound.    


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• Hyperandrogenism will be determined by evidence of hirsutism on exam or by 
biochemical elevations in total testosterone.  
• Ultrasound findings of polycystic ovaries including > 12 follicles of 2-9 mm 
diameter or increased ovarian volume (>10 cm3) in either ovary.   


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5 STUDY ENROLLMENT AND WITHDRAWAL 
5.1 
Subject Inclusion Criteria 
In order to be eligible to participate in this study, the participant must meet all following 
criteria: 
1. Provide signed and dated informed consent. 
2. Willing to comply with all study procedure and be available for the duration of the 
study.  Ability to have regular intercourse during the ovulation induction phase of the 
study. 
3. Diagnosis of 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.11 If in the clinical case of anovulation, 12 month period of time 
“infertility” is not necessary.   
4. Diagnosis of polycystic ovary syndrome: based on Revised Rotterdam criteria which 
includes two of the three following findings12 and the definitions and criteria are modified 
from the PPCOS II trial9: 
 
1. Oligomenorrhea or chronic anovulation: spontaneous intermenstrual periods of 
> 45 days or a total of < 8 menses per year. In women with more regular bleeding 
patterns but suspected anovulatory bleeding, a mid-luteal serum progesterone level < 3 
ng/mL is consistent with chronic anovulation. For women with a history of < 8 menses 
per year however now have regular menses due to initiation of insulin sensitizing agents 
or active weight loss efforts within the last year prior to the study would qualify as 
evidence of oligomenorrhea.   
 
2. Hyperandrogenism (clinical or biochemical): clinical hyperandrogenism 
demonstrated by hirsutism and biochemical hyperandrogenism demonstrated by 
hyperandrogenemia. Hyperandrogenemia defined as an elevated total testosterone 
based on the laboratory criteria. Labs could be local or from UIHC.  
 
3. Polycystic ovaries on ultrasound: defined as either an ovary that contains 12 or 
more follicles measuring 2-9 mm in diameter, or an increased ovarian volume (>10 cm3) 
on one ovary.   
 
 
5. Normal sperm concentration of 15 million/mL and with normal motility of > 40% 
according to World Health Organization cutoff points, in at least one ejaculate during the 
previous year.13  Morphology results will not affect eligibility. If male partner has fathered 
a child, SFA is not necessary.  


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5.2 
Subject Exclusion Criteria 
 
1. Current pregnancy. Patient will take a urine pregnancy test prior to starting 
treatment medication.  
 
2. Patients currently taking hormonal contraception.  A 1 month washout for any 
type of combined contraceptive or oral progestins will be required.  If use of hormonal 
implants or depo progestins a longer washout of 3 months will be required.   
 
3. Patients with other known cause of infertility: endometriosis, tubal factor, 
uterine abnormalities.  
 
4. 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 year is 
adequate for entry.  
 
5. Patients with untreated hyperprolactinemia.  A normal prolactin within the past 
year at local lab or at UIHC (4.8 to 23.3 ng/mL) is adequate for entry. 
 
6. Medical conditions in which we recommend avoiding pregnancy until under 
improved control: 
 
-Patients with poorly controlled Type 1 or Type 2 diabetes (defined as a 
hemoglobin A1c > 6.5%) 
 
- Patients with poorly controlled hypertension (defined as systolic blood pressure 
> 160 mm Hg or diastolic > 100 mm Hg on two measures at least 60 minutes apart)   
 
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. 
 
 
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).  


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6 STATISTICAL CONSIDERATIONS 
6.1 
Justification of effect size  
6.1.1 
Prior Studies 
The primary outcome is ovulation, defined by a mid-luteal progesterone level > 3 ng/mL. 
There is data demonstrating the cumulative live birth rate with clomiphene and letrozole 
from the PPCOS II trial. This trial compared letrozole to clomiphene demonstrated that 
letrozole was associated with a higher cumulative ovulation rate (61.7% vs. 48.3%, 
P<0.001) among women with polycystic ovary syndrome and the rate of ovulation after 
one treatment cycle with letrozole 2.5 mg was 50%.9   Unfortunately, there is no 
comparative quality data from randomized trials of the combination of letrozole and CC.  
There is one study that prospectively reviewed treatment outcomes using a combination 
of letrozole and clomiphene who had previously failed CC for 6 cycles and letrozole for 
4 cycles.  This study enrolled 100 patients and showed an ovulatory rate (defined by 
development of dominant follicle) of 82.9% of cycles (213/257) with the combination 
treatment.10  However, this study was not randomized and used a limited population of 
women with PCOS that were resistant to both clomiphene and letrozole alone. 
Additionally, patients received Gonal-f on day 11 if a dominant follicle was present and 
then received hCG trigger when the follicle was >18 mm in size followed by IUI 36-38 
hours later.   
6.1.2 
Minimum Clinically Important Difference 
Since this is a pilot study our goal is to balance the risk of avoiding a type 2 error and 
having an attainable sample size.  We have set a benchmark of 30% difference 
between groups as a clinically meaningful.  
6.1.3 
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 model to adjust for other factors such as the 
randomization stratification of age and BMI and prior exposure to study medications.  A 
per protocol analysis will also be performed.  
6.1.4 
Sample Size calculations 
A sample size of 31 subjects in each arm of the randomization yields 80% statistical 
power to prospectively demonstrate a 0.30 absolute difference in ovulation rate between 
treatment arms (0.50 for Letrozole and 0.83 for combined letrozole and CC) using the 
Pearson’s chi-square test having a two-sided significance level of 0.05. The sample size 
has been inflated to 35/arm to allow for a dropout rate of 10%. Dropout rate in the 
PPCOS II trial was 19.5% in the letrozole group however this was a longer study in 


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which they did 5 cycles and also a more involved study than the one we are proposing.  
Since there are fewer visits, fewer surveys and shorter enrollment period we anticipate 
a lower dropout rate in this trial.   
 


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