# Clomid (aka Clomifene)



## Anthony Reid (Jan 1, 2002)

*Clomid*

Why use Clomifene?
Who might benefit?
Preliminary testing
How does it work?
Taking Clomifene tablets.
Are there any side effects?
The risk of Ovarian Hyperstimulation Syndrome.
What is the success rate?
Are there any other issues?

*Why use Clomifene?*

Doctors prescribe Clomifene when they believe that your infertility may be caused by failure of your ovaries to ovulate (release eggs).

When your ovaries fail to release eggs, it is known as anovulatory infertility.

Clomifene releases hormones and makes you more likely to ovulate each month. It is arguably the most widely used fertility drug and a very well established treatment .

*Who might benefit?*

Women who do not ovulate or do so very irregularly, and also those suffering with polycystic ovaries. Sometimes Clomifene is prescribed when there is no other obvious reason for infertility.

*Preliminary testing*

Your doctor will want to asses your fertility by performing some initial diagnostic blood tests which will assess your reproductive health and more specifically, the levels of hormones in your body.

Day three of your menstrual cycle is when the first blood test is used to assess both your Follicle Stimulating Hormone (FSH) and Luteinizing hormone (LH). The results will indicate any imbalance that may be having a negative affect on your ability to achieve pregnancy.

Later on during your menstrual period, specifically day 21 - your progesterone levels are then tested to see if they are elevated. This is because progesterone production is increased after releasing an egg.

This test will also identify if there is a sufficient level of progesterone to maintain a luteal phase. The luteal phase commences the day after ovulation and lasts between twelve and sixteen days, during which time progesterone levels increase in order to develop a fertile environment for the egg.

A third blood test may also be conducted in order to check thyroid issues that may also be effecting chances of conception.

*How does it work?*

Clomifene citrate, the active ingredient in Clomifene is an anti-oestrogen medication which stimulates an increase in the levels of hormones which in turn effect stimulation of the ovaries and hopefully the release of an egg.

Once Clomifene has induced lower levels of oestrogen, the body then increases luteinizing hormone (LH) and follicle stimulating hormone (FSH). Which then cause the ovaries to begin to mature more follicles.

Your pituitary gland is stimulated to develop more FSH(Follicle stimulating hormone) to trigger ovulation. Once your FSH levels are elevated your ovaries prepare a number of your eggs. On completion of your drug cycle, your hypothalamus causes the release of (LH)luteinising hormone. This is when your ovaries are instructed to release a mature egg and send it on its path down one of your fallopian tubes.

*Taking Clomifene tablets.*

Clomifene is typically started two to five days into your period and the usual starting dose is one Clomifene tablet (50mg) each day for five consecutive days - although your doctor may feel a higher does is necessary.

Your doctor will ask you to take your temperature every day and from this record your doctor will be able to tell if you have ovulated. If after you have not started a period then you should have a pregnancy test. If you are pregnant, you should NOT take another course of Clomifene tablets.

If the Clomifene cycle failed to produce a positive pregnancy test, yet you did ovulate - then you should consult with your doctor about an additional course at the same dosage (one tablet each day for five days), up to a maximum of three cycles. It is normal for your doctor to check your ovaries via ultrasound before each cycle of treatment. Your doctor will check that your ovaries are preparing follicles and releasing eggs into one of your fallopian tubes.

If ovulation does not occur after three courses, then you are not likely to benefit from any further courses of Clomifene. However some Doctors have been known to prescribe up to twelve courses. The arguments for this are that it can take a couple of months for the drug therapy to cause regular ovulation.

For women who have been diagnosed with PCOS(polycystic ovarian syndrome) - Clomifene may not be effective - due to a resistance to the drug. It is estimated that this is the case for around 15 to 40 percent of PCOS sufferers.

If there are factors that prohibit Clomifene from being effective (such as PCOS or a high BMI) then your doctor may additionally prescribe Metformin, an insulin-sensitising drug. Metformin can help you respond to Clomifene and some studies have shown an increase the chances of ovulating and getting pregnant.

*Are there any side effects?*

Some people have no symptoms of side effects, while others may experience some. Every individual reacts differently.

Side effects include:

• Feeling bloated, puffy or uncomfortable
• Hot flushes
• Putting on weight.
• Slight increased risk of multiple pregnancy
• Mood swings
• Dry cervical mucus,
• Mild ovarian swelling,
• Stomach pain
• Breast tenderness
• Insomnia
• Nausea and vomiting
• Blurred vision,
• Headaches,
• Fatigue
• Irritability
• Depression

*The risk of Ovarian Hyperstimulation Syndrome.*

OHS occurs where the patient's ovaries over responded to the medication. This is usually when additional drugs such as human menopausal gonadotrophin (hMG) have been prescribed to work along side Clomifene.

The ovaries are enlarged and fluid 'weeps' into the abdominal cavity (and sometimes the chest as well). This can be assessed by ultrasound assessment.

Typical Symptoms.

1. The patient may complain of breathlessness and be breathless

2. Pain and swelling in the abdomen. As fluid builds up in the abdomen the patient will experience a feeling of being bloated.

3. Nausea. The patient may feel sick and may even vomit

4. Feeling faint/dizzy

5. A decrease in the amount of urine being passed.

Identifying the patients who are at risk of OHSS is crucial.

About 4% of women undergoing an fertility cycle are likely to develop one or more of the symptoms listed above. Monitoring in these cases is particularly important. The patient may be asked to rest and in some cases, the treatment cycle may have to be cancelled. However, the management of the condition does not always call for the cancelling of a cycle. Once the symptoms have been identified the doctor may be able to advise a patient to 'coast' that is allowing the patient to continue developing follicles while removing the stimulation drug from her treatment regime. A patient can coast (subject to clinic being used) for several days with frequent blood tests to assess her response. Treatment may then go ahead if the doctor is happy with the patient's progress. In general terms, patients who coast are generally successful in getting pregnant.

In some cases where a patient remains symptomatic, she may still have her egg retrieval but be advised to have an elective freeze. This means that the embryos are not transferred but are frozen for future use. In this instance the patient has time to overcome the stimulation and have the embryos transferred when she is feeling better. This decision to freeze would be made by the doctor if it is in the patient's best interest.

If a patient is not feeling better and still retains a significant amount of fluid, the fluid can be drained. This may need to be carried out several times. Ideally it is carried out vaginally because this method allows the fluid to be removed easily. Most importantly this out-patient management usually allows the patient to avoid hospital admission. If a patient does undergo fluid drainage, she will usually feel enormous relief immediately afterwards.

Over the next few days, urinary output will be measured, as well as her weight and abdominal girth. She will phone the clinic each day to report on how she is feeling and is monitored very closely.

Although OHSS is rare, it is extremely important that a patient raise any concerns she may have sooner rather than later so if it is a cause for concern it can be treated immediately and effectively, contact your clinic immediately if you suspect OHSS or are having symptoms as mentioned above.

Normally this resolves itself with careful monitoring by your doctor, but in rare cases it can be life threatening.

*What is the success rate?*

Success rates vary. This is due to a wide range of factors affecting pregnancy. Age, Weight and conditions of your partners sperm will all affect your chances of being successful.

It is estimated that around 70% of women will achieve ovulation within the first three months of fertility drug therapy and between 15% and 50% of those will become pregnant.

*Are there any other issues?*

The chances of a multiple pregnancy are increased with Clomifene due to that fact that stimulated ovulation may result in more than a single egg being released. Current studies have shown that women who are prescribed clomifene are around 7% more likely to achieve a twin pregnancy and have about 0.5% of conceiving triplets.


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