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Frederick R. Jelovsek MD
"My doctor prescribed Clomid® and told me how to use it but I don't get my period every month. I have some birth control pills left. Should I use them so I can start the Clomid®?". K.
I feel very badly that you did not get instructions on how to take the Clomid®(clomiphene citrate). This reflects poorly on the medical profession because induction of ovarian ovulation can be somewhat complicated. You actually need detailed instructions depending upon what condition you have and which regimen the doctor likes to use.
Do I need to have a menstrual period induced before taking clomiphene?
In theory no, but in practice yes. If you knew for sure you had not ovulated and become very early pregnant, then inducing a menses would not be necessary. The reason most doctors give you progestins or progesterone to induce a menses is to make sure you have not recently ovulated or become pregnant. If you just ovulated, the progestins will usually not induce a menses until 14 days after ovulation. This protects you from inducing an ovulation on top of an ovulation or disrupting an ovulation and potential pregnancy with unneeded clomiphene.
Another reason to induce a menses before Clomid® is to make sure the lining of the uterus is at the right phase for egg implantation. If a menses is induced, then the endometrial lining has had only 14 days of growth and stimulation at the time of ovulation. When no menses is induced, the endometrium has been growing and been stimulated for 30 or more days and may not be as receptive to egg implantation.
Finally, if a menses is induced, the doctor knows for sure that you are not pregnant. Even if you use the most sensitive home pregnancy test you could still be pregnant with a negative test. Thus having a menstrual period is good reassurance that you are not pregnant and that the lining of the uterus is best prepared for an ovulation and potential pregnancy.
Birth control pills can be used instead of the progestins if that is all you have. They would be taken for 5 days, one each day, just as you would take progestins orally (e.g., Provera®). The menses may start anywhere from 2 days to about 2 weeks after finishing the progestins or birth control pills.
After my period, when do I take the clomiphene?
The most common regimen is to take the clomiphene starting on day 5 after the start of menses for 5 days ending on day 9. Another regimen is to start on day 4 through 8 and a recent publication even indicates the Clomid® can be taken on day 1 through day 5 with a very successful pregnancy rate. If your doctor does not indicate otherwise, taking the medicine on days 5-9 is the usual and most commonly tested regimen.
Sometimes a 3 day regimen can also be used although it is not quite as successful at inducing ovulation, it may have a slightly higher pregnancy rate since the anti-estrogen effects of Clomid® on the endometrium are less pronounced.
What should I expect or look for after taking Clomid®?
Most women do not have any symptoms from taking Clomid®. Some will have some lower abdominal cramps in the 2nd half of the cycle. Rarely (less than 1-2%) a woman may experience ovarian hyperstimulation syndrome. In this case the ovaries become quite enlarged and multicystic. They can cause moderate pelvic pain. There can also be large amounts of fluid secreted into the abdominal cavity (ascites). Sometimes the fluid can be so severe that it can cause heart or kidney failure.
If you have any pelvic pain or discomfort other than a few mild cramps, you should let your doctor know in case you may need an exam.
As far as the efficacy of clomiphene in inducing ovulation, its success depends upon the underlying cause of why you do not ovulate. If you have polycystic ovarian syndrome it is more sucessful than if the cause of ovulation is hypothalamic anovulation.
When can I check to see if I got pregnant using the Clomid®?
First it is best to check if you ovulate using the Clomid®. Most women do this by monitoring their basal body temperature. This basal (morning) temperature goes up by about 0.5 degrees F or more (BBT graph) and stays up during the luteal phase. Ovulation may occur anywhere from day 12 of the cycle up to day 18 of the cycle or occasionally later using Clomid®. If the temperature stays up for 17 days or more after ovulation, then you should run a pregnancy test. If it is positive, let your doctor know.
There can be a slightly higher early pregnancy loss rate with clomiphene induced ovulation so if you have trouble interpreting your basal body temperature and pregnancy test results, be sure to contact your physician.
What happens if I do not get pregnant this cycle?
If you ovulated and the pregnancy test is negative, then you should take another course of progestins and start over with ovulation induction at the same dose. If you did not ovulate, you will need instructions from your doctor as to whether to increase the Clomid® dose. Often the dose is increased from 50 mg to 100 mg, to 150 mg and then to 200 mg and at most 250 mg if no ovulation occurs at the lower doses. Do not increase the dose on your own without instructions from your physician.
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