Clomid - What, Why and How
Contributed by Angie Boss, Staff Writer
Clomid - the very name is enough to strike fear in the hearts of husbands of infertile women everywhere. After a few days of it, my husband will wistfully ask, "Why aren't there hormone-free safe houses for men to go to?" Often the first line of defense when it comes to infertility medication, it is often among the worst offenders when it comes to emotional side effects. On the other hand, Clomid is a good fertility medication and doesn't require injections, which is always a plus.
What is it?
Clomiphene citrate is frequently referred to by its brand names, Clomid and Serophene. Clomiphene is used to induce ovulation, to correct irregular ovulation, to help increase egg production and to correct luteal phase deficiency. It is one of the selective estrogen receptor modulators that acts as an anti-estrogen and tricks the pituitary gland into producing more FSH and LH, which, in turn, stimulates the ovary into producing more eggs and follicles. Generally, Clomid follicles are larger than injectible follicles right before ovulation
What should I know before taking it?
If there is a male factor involved in your inability to get pregnant, Clomid will not fix the problem. In fact, that's why most physicians suggest a thorough exam and adequate laboratory testing before beginning Clomid. One would not want to arbitrarily begin taking Clomid if there are other problems that need to be addressed, as it would not necessarily be of any value in the face of other unrelated factors. Especially if you're paying out of pocket, unproductive overuse of the drug can get expensive.
What constitutes a thorough exam and adequate laboratory testing?
Preliminary fertility testing should consist of a cycle day 3 ultrasound, a hysterosalpingogram (HSG - to check the condition of the fallopian tubes and to make sure there are no uterine anomalies), cycle day 3 bloodwork (to check FSH and LH levels), and a progesterone/prolactin check (bloodwork) seven to nine days after ovulation. A semen analysis for the partner is just as important. Ideally, doctors would try to find out why a couple is not achieving a pregnancy. "I walked in to my doctor's office, told him I had been trying to get pregnant for a year and wanted to try Clomid," remembers Dawn, a 34-year-old woman. "He said 'ok' and wrote me a prescription with six refills. I wasted six months before anyone realized I had blocked fallopian tubes."
How do I take it?
Clomiphene citrate comes in 50-mg tablets that are taken on days 5-9 of your cycle or, less typically, on days 4-8 or 3-7. There is some preliminary research that indicates that an earlier start date may result in more pregnancies, but most gynecologists continue to prescribe it for days 5-9. One recent study (Biljan et al, cited below) actually tried prescribing Clomid on cycle days 1-5. While none of the participants in their day 5-9 group resulted in pregnancy, 24 percent of the women who took Clomid on days 1-5 were able to conceive.
Daily doses range from 50 mg to 200 mg. A few doctors will prescribe as much 250 mg per day, but this is rare and goes against manufacturer's suggestions. The Merck Manual, a reputable sourcebook for health care professionals, suggests no more than 150 mg per day.
What can I expect?
Just as women's bodies are so different from one another, their reactions to Clomid vary tremendously. Some women have virtually no side effects. Others do, but they are more frequently related to emotions. As Lana describes her three months on Clomid before moving on to other medications: "Hormone hell is probably the best way to describe it. By the third or fourth day of taking it, I would become hysterical for absolutely no reason. I felt as if I had no control over my body. I began to wonder if this was worth it. But, it only lasted a few days, and we all got through it. But it wasn't fun."
Other side effects may include mood swings, hot flashes, breast tenderness, and thinning of the uterine lining. Multiple gestation pregnancies may occur (about an 8-10 percent occurrence in those who get pregnant). Ironically, Clomid can cause hostile fertile mucous and thins the uterine lining in over 30 percent of the women who use it. The hostile mucus kills sperm, and the thin uterine can prevent implantation or cause an early miscarriage.
Can I afford it?
On a more positive note, Clomid is one of the more affordable fertility drugs, and it has a generic equivalent. A five-day supply of 50-mg tablets can run from $15 to $35. Obviously, it gets more expensive when you triple or even quadruple the dosage. Generally, research shows that if the drug doesn't work in four to six cycles, it isn't likely to work. However, if you take a break and start over, perhaps with the addition of HCG or an insulin sensitizer for women with PCOS, then you may elect to start the four to six cycles over again.
What are the risks?
As with most ovulation-inducing drugs, there is a risk of ovarian hyperstimulation. Cysts can erupt and ovaries can be enlarged. This is rarely serious and is more common with other fertility medications. However, if you are taking this medication and have unexplained pain, call your doctor. A quick ultrasound can determine if there are any problems. This drug should not be taken if you are pregnant or have a history of liver disease.
Several years ago, there research findings were reported stating that Clomid increased a woman's chance of getting cervical cancer. The data associated with that study have since been found to be flawed, and many physicians discredit the researchers' conclusions. However, if you have concerns, talk to your physician about them.
How will I be monitored?
Many physicians will not perform routine ultrasounds on a Clomid cycle unless an HCG is added. However, on or around cycle day 21, a progesterone check (blood draw) is often done. Ideally, clomiphene would trigger higher progesterone production, which can improve the quality of the uterine lining and/or lengthen the luteal phase of the cycle.
In addition, an ovulation predictor kit can be used to test for an LH surge. Each kit is different and you may need to test on a different day when on this drug - do read the instructions carefully. Clomid can create hostile cervical mucus or dry up the mucus, in which case a postcoital test may be done. However, this would not be necessary when undergoing intra-uterine insemination (IUI).
Once on Clomid, the only way to determine if it is "doing it's job" is proper monitoring. A cd 3 scan may reveal any cysts, another scan around cd 11 or 12 may be conducted to check follicular development and the lining, and a progesterone check six or seven days past ovulation may be performed to see if progesterone levels are high enough to support a pregnancy (p4 levels should be "15" or better). Also, a post coital test (PCT) should be done when either blood work or ovulation predictor kits detect an LH surge. If hostile mucous presents a threat to the sperm, then an IUI should be done. When follicle(s) are big enough, an HCG shot followed within 36 hours by an IUI procedure may provide optimal results.
What's the Bottom Line?
The risks are minimal, it doesn't hurt to take it, it's relatively inexpensive, and overall, Clomid is a good fertility medication. "Without Clomid, I wouldn't have had Benjamin," says Tammy, a new mom at 34. "On our third Clomid cycle, I conceived and everything was wonderful. I would do it again in a heartbeat."
Marinko M. Biljan, Neal G. Mahutte, Togas Tulandi, and Seang Lin Tang; McGill Reproductive Center, Department of Obstetrics and Gynecology, Royal Victoria Hospital, McGill University, Montreal, Quebec, Canada
