Induction of Ovulation
with Clomiphine Citrate (CC)

If your infertile couple is quite clearly anovulatory (based on history, basal body temperature graphs and normal semen analysis) then it is reasonable for you as a family practitioner to try a few courses of CC before referring to a gynecologist.
The following is a protocol for the use of CC in this setting.

1. Do a routine PV exam to rule out palpable ovarian cysts
2. Do the appropriate tests to rule out hypothyroidism, hyperprolactinemia,and pregnancy.
3. Explain to the patients that there is a 10% chance of twinning and of ovarian hyperstimulation.
4. Start Folic acid at a dose of 0.4 mg po daily (to reduce the incidence of neural tube defects).

    

   1	5-------->9	13-------->19	25	28--->30
   	Clomiphine	Fertile Period	Progesterone Level	Menses

Day 1 - First day of bleeding (if the patient is totally amenorrheic induce bleeding with Provera 5-10 mg. daily for 5-10 days).

Day 5-9 - Clomiphine Citrate 50 mg daily. Side effects of flushing, nausea, headache, bloating and irritability may be noted in up to 10% of patients.

Day 13-19 - Fertile period. Intercourse every two days is adequate

Day 25 - A progesterone level can be done to confirm ovulation

Day 28 -33 - Menses 14 days post ovulation

Note : - Menses at the predicted time probably means that she has ovulated. About 60-80% of patients will ovulate. Of these approximately 50% will conceive.

Basal body temperature graphs and monitoring cervical mucous consistancy may help the patient to better understand her cycle and may help the practitioner determine whether or not the patient has ovulated. Urinary LH levels and transvaginal ultrasonography may also be used to detect ovulation.

If the patient is amenorrheic at the end of the cycle either clomiphine failed to induce ovulation or the patient is pregnant, so do a pregnancy test prior to restarting the Clomiphine.

Do early first trimester Ultrasound to rule out multiple pregnancy. There is a 10% risk of twins and about one in four hundred chance of triplets.

Use of Clomiphine citrate can increase the risk of ovarian cancer by a factor of 2-3. The risk in the normal population is about 1-1.5%. The risk in women who have taken CC for more than 12 cycles and have not conceived is about 4-5%. The usual treatment course is 4-6 cycles.

Close follow up is required.

Cost is about $40.00 per month.

- Alison Wright