Dear Readers,
Recently, I received a private question regarding the use of Clomid in a natural ovulation cycle. This 31 year old patient has been seeing an OB/Gyn for her infertility evaluation and treatment. She has gone through eight failed natural cycles, "diligently" using ovulation charts and opk's. After seeing her doctor, she was put on Clomid. "My first appointment, she never asked me what specific day I was ovulating, just ordered the blood work. Thus, I scheduled the second appointment to assert my concern. She proceeded to prescribe me 50mg of Clomid on days 5-9." Unfortunately, this patient failed with her first cycle using Clomid and is unsure how to proceed.
I know that there are many of you out there with similar concerns, so I have decided to publish my response to her question by outlining my Clomid timed ovulation protocol. As an infertility specialist and an Ob/Gyn, this is the approach that has yielded success for me with patients like the one above.
Her closing concerns mirror many others I have received in the past: "What would be your advice for me at this point in the process? Should I be patient and continue with Clomid and not be concerned with late ovulation? Should I go to a different ob-gyn or assert myself more with my current Dr? Or, should I go to a fertility specialist?".
Answer:
Hello J. from the U.S.,
First, let me explain how I do Clomid ovulation induction cycles, which is the way that I recommend. I DO NOT recommend just taking clomid and trying to time intercourse on your own (noninterventional method), which is what a lot of OB/GYN's like to do.
1. Patient calls with onset of period or within the first five days of onset. She is scheduled to be seen within the first five days of the cycle.
2. Patient comes in for a baseline ultrasound to evaluate for the presence of an ovarian cyst. Ovarian cysts are a contraindication to using fertility medications and will interfere with the cycle. The cyst may just get bigger and ovulation will not be accomplished.
3. Treatment calendar is made up showing when everything is going to happen, approximately.
4. Patient stops having intercourse on cycle day #10.
5. Patient returns on cycle day #10, 11 or 12 for vaginal ultrasound to check for: whether she is responding to that dose of Clomid as manifest by multiple growing follicles, how many follicles are growing and if the follicular size is appropriate for ovulation. Serial daily or every other day ultrasounds are done until the ovulatory follicle(s) reach the appropriate size of 18-24 mms.
6. Once the follicles reach the appropriate size, HCG is given to trigger ovulation.
7. If a timed intercourse cycle, the patient begins intercourse the next day for four consecutive days, only one ejaculation per day. If an IUI cycle, the patient has an IUI the next day and following day.
8. Vaginal progesterone is then started either on the 5th day after trigger if a timed intercourse cycle, or the day after the second IUI, and continued until the pregnancy test.
9. Blood pregnancy test is done two weeks after the trigger and the progesterone is NOT stopped until this result is negative. If positive, it is continued until 10 weeks gestational age. We DO NOT wait for onset of menses, because often it will not come if progesterone is taken.
If this is not the way that your doctor is using Clomid, then he/she is not treating you appropriately in my opinion, and you should find someone who will. Usually a fertility specialist is the appropriate choice, but there are many general Ob/Gyn's who do fertility well. The purpose of Clomid in your case, is to get your ovaries to function normally. Usually that will regulate your ovulatory cycles and you will ovulate by cycle day # 14. Clomid often shortens the follicular phase (first two weeks), if an appropriate dose is used. Clomid can be given in doses from 50 mg to 250 mg. The doctor has to find what the lowest appropriate dose is and that is done by trial and error. Without checking with the ultrasound, he/she can't know how you are responding. In clomid cycles you don't want more than 5 ovulatory sized follicles. Also, you don't want to do consecutive months with Clomid because it blocks estrogen receptors and can lead to poor endometrial lining and poor cervical mucous. Clomid is one of the most misused drugs in the U.S.
Sorry for the mass of information, but I hope this will give you what you need to know to make an appropriate informed decision.
Good Luck,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
Monterey, California, U.S.A.
