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Hepatitis C: what do you need to know if trying to conceive

Hepatitis C: what do you need to know if trying to conceive

Hepatitis C: what do you need to know if trying to conceive

Hepatitis C Infection

Hepatitis C Virus (HCV) infects 3% of the world’s population. Over 170 million chronic carriers. Approximately 2.7 million Americans (1.8%) are infected with HCV in addition to 30,000 new cases reported yearly. In the United States, 65% of persons with HCV infection are aged 30-49 years. There are several types of the virus that vary in geographical distribution and response to medications.

HCV prevalence

Genotype 1a occurs in 50-60% of patients in the United States. Genotype 1b occurs in 15-20% of patients in the United States; this type is most prevalent in Europe, Turkey, and Japan. Genotype 1c occurs in less than 1% of patients in the United States

Genotypes 2a, 2b, and 2c occur in 10-15% of patients in the United States; are widely distributed and are most responsive to medication

Genotypes 3a and 3b occur in 4-6% of patients in the United States;  most prevalent in India, Pakistan, Thailand, Australia, and Scotland

Genotype 4 occurs in less than 5% of patients in the United States; it is most prevalent in the Middle East and Africa

Genotype 5 occurs in less than 5% of patients in the United States; it is most prevalent in South Africa

Genotype 6 occurs in less than 5% of patients in the United States; it is most prevalent in Southeast Asia, particularly Hong Kong and Macao

Transfusion of blood contaminated with HCV was once an important source of transmission. Since 1990. Persons who inject illegal drugs with non-sterile needles or who snort cocaine with shared straws are at now at the highest risk for HCV infection.

Transmission of HCV to health care workers may occur via needle-stick injuries or other occupational exposures. Nosocomial patient-to-patient transmission may occur by means of a contaminated colonoscope, via dialysis, or during surgery, including organ transplantation before 1992.

HCV may also be transmitted via tattooing, sharing razors, and acupuncture. The use of disposable needles for acupuncture, which has become standard practice in the United States, eliminates this transmission route. Other uncommon routes of transmission of HCV, which affect less than 5% of the individuals at risk, include high-risk sexual activity and maternal-fetal transmission. 10% unknown.

Tests for detecting hepatitis C virus (HCV) infection include:

  • Hepatitis C antibody testing
  • Recombinant immunoblot assay
  • Qualitative and quantitative assays for HCV RNA
  • HCV genotyping

Hepatitis C Treatment

Significant progress in the treatment of hepatitis C infection took place in the past year. Several medications or combinations can lead to cure in about 10 weeks in the majority of hepatitis C infected patients. Medications include Sovaldi (sofosbuvir 400 mg), Harvoni (ledipasvir (90 mg)/sofosbuvir 400 mg)  or Vikera pak, with or without ribaverin.

One treatment regimen is  a single daily tablet of ledipasvir 90mg / sofosbuvir 400mg for 8 to 24 weeks (according to genotype, viral load and functional status of the liver).

Hepatitis C and Reproduction

Significant effort is excreted by reproductive endocrinologist to detect hepatitis C and other viral infections and to prevent the transmission of hepatitis C to women and babies during reproduction.

Intimate partners: both partners are screened for HCV antibodies. If one partner is infected, he or she is referred for treatment with one of the modern drug regimens for 8 to 12 weeks before fertility treatment. If viral load does not drop to an undetectable level then a protocol exists for infected men to test semen for the virus and use the frozen sperm for IVF and ICSI to minimize transmission to mother and baby.

Egg and sperm donors: extensive history, exam and screening for donors is performed. Those with high risk factors are excluded. Donors with no risk factors are further tested using hepatitis C antibody and hepatitis C RNA performed in an FDA approved lab. Sperm donors are tested before sperm donation, sperm are quarantined for 6 months and the donor is retested again before releasing sperm. Egg donors are tested in an FDA approved lab within one month of egg retrieval. So far, there is no reported case of hepatitis C transmission after sperm or egg donation.

Gestational carriers: Intended parents are screened in an FDA lab for viral infections to minimize transmission to surrogates. Gestational carriers are also screened to prevent transmission to the baby.

Frozen sperm, eggs and embryos: liquid nitrogen in storage tanks can very rarely transmit infection. All patients are screened before storage. Tissues and cells can be stored in nitrogen vapor and sealed devices. Liquid nitrogen can also be filtered and sterilized using ultraviolet rays.

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Melanoma-What Every Woman Need to Know about Fertility and Pregnancy

Women diagnosed with melanoma may require counseling for fertility preservation, fertility treatment and safety of pregnancy after treatment. Melanoma is one of the most common cancers in young adults in the United States. In the US and worldwide, there is  dramatic increase in the incidence  of skin melanomas. Approximately 30,000 women are expected to be diagnosed with melanoma in 2010, one third will be in their reproductive years. Its the most common cancer in young adults 25 to 29 year old. Its more common in white women compared to African Americans and Hispanics.  Approximately  10% of melanomas run in families or are genetically inherited. Treatment of melanoma requires surgery. In advanced melanoma, chemotherapy is added. Dacarbazine-DTIC is an alkylating agent used for treating melanomas. Immune therapy is also used for advanced melanomas- interferon α or IL-2.

In early stages, surgery is the only required treatment. In advanced stages if chemotherapy is used, ovarian reserve may be diminished and this may reduce woman’s ability to get pregnant. The use of immune therapy is not known to affect future fertility. The effects of newer targeted therapies and vaccines on fertility are also unknown.

Melanoma and fertility treatment. The estrogen receptors were found on melanoma cells. Some researchers detected no significant increase in the risk of melanoma after treatment with fertility drugs, except possibly slight increase in risk in women who delivered children before. The relationship between estrogen exposure and melanoma is controversial. Women seeking fertility preservation before exposure to chemotherapy or melanoma survivors desiring pregnancy after completing treatment should consult with a fertility preservation specialist about the risks and benefits of fertility treatment and the safety of pregnancy. The ovarian stimulation regimen can also be modified to minimize estrogen exposure. It may also be possible for women with inherited predisposition to melanoma to avoid transmission to future children through testing of embryos-PGD.

Melanoma and pregnancy. Ten studies including 5600 women found that pregnancy does not reduce survival in women diagnosed with melanoma. Women treated for melanoma who subsequently became pregnant were not adversely affected compared to women who did not get pregnant after treatment. For thin tumors-<1.5mm most experts do not recommend deferring pregnancy. For thicker tumors, physicians may recommend deferring pregnancy for two years as most recurrences take place during that interval. Read more at http://nycivf.org

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What Does Borderline Ovarian Tumor Mean to Your Fertility?

What Does Borderline Ovarian Tumor Mean to Your Fertility?

Fertility in women diagnosed with borderline ovarian tumors can be reduced or lost due to surgical treatment. Counseling regarding fertility preservation shortly after diagnosis can increase the chance of pregnancy following treatment.

Borderline-low malignant potential ovarian tumorLow malignant potentials

The cells in borderline tumors, proliferate more than benign ovarian cysts but less than frank malignant ovarian tumors. Multiple layers of these cells are seen on pathology slides, but they do not invade surrounding tissues as in malignant tumors. They are diagnosed in approximately4000 of women each year in the US and are more commonly encountered in reproductive age women. These tumors are usually cystic, sometimes with surrounding implants. Low malignant potential tumors are treated surgically (removal of cyst, removal of the ovary or sometimes removal of both ovaries and the uterus). They generally do not require chemotherapy for treatment. The majority of these tumors are associated with very high survival (10 year survival >90% in stage I and II ), although some may recur or turn malignant.

There is no difference in survival if borderline tumors were treated with removal of the cyst, removal of the ovary or removal of the uterus and both ovaries. Recurrence may be lower after hysterectomy (5%) compared to salpingoophorectomy (15%) and cyst excision (30%). The high rate for recurrence after conservative surgery indicates the need for strict and long term follow up (pelvic exams, ultrasound and tumor markers). Some recurrences take place years after initial surgery and are sometimes malignant.

Fertility risks in women diagnosed with borderline tumors

Fertility risks in women diagnosed with low malignant potential ovarian tumors include loss of ovarian tissue and pelvic scarring that can block the fallopian tubes especially if open approach is used for treatment compared to laparoscopy (minimal acess surgery). Some loss of ovarian tissue does occur even during cyst removal from the ovary. Ovarian reserve can be tested after surgery using transvaginal ultrasound evaluation for ovarian volume and number of antral follicles. Ovarian function can also be assessed using day 2 FSH and estradiol levels and antimullerian hormone (AMH).

Fertility preservation strategies in women diagnosed with borderline ovarian tumors

1. Conservative surgery

Ovarian cystectomy can be considered in reproductive age women, especially in early disease with favorable pathology and absence of implants. Recurrence is relatively high but can be managed with repeat excision if not malignant. If pregnancy is desired following surgery, fertility factors; ovulation, fallopian tubes and sperm factors should be investigated and treated accordingly

2. Embryo and oocyte cryopreservation

Women at risk for diminished fertility due to surgery, especially if requiring removal of the ovaries or repeat excision of cyst, can consider ovarian stimulation, egg retrieval and egg freezing or  IVF and embryo freezing. There is no evidence that ovarian stimulation and exposure to high estrogen increases the risk for recurrence. It is not clear if border line cells are sensitive to estrogen increase during ovarian stimulation. Two options are available to reduce estrogen exposure: to perform IVF in a natural cycle (low egg yield) or to modify the stimulation protocol, through adding an aromatase inhibitor, similar to that used for breast cancer. Alternatively, short stimulation followed by retrieval of immature eggs followed by in vitro maturation can be performed.

Women diagnosed with borderline ovarian tumors are at risk for diminished fertility because of surgical treatment(s). This is especially true if repeat surgical excision is required. Collaboration between a gynecologic oncologist and a reproductive endocrinologist enable adequate surgical treatment, strict follow up and preservation of future fertility in reproductive age women.

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What if You Have Dual Infertility Factor

What if You Have Dual Infertility Factor

What if You Have Dual Infertility Factor

Many Times You Do

Infertility factors are generally classified into tubal factor (blocked fallopian tubes), male factor (abnormal sperm concentration, movement or shape) and ovarian factor (no ovulation). In the majority of situations though multiple factors exist. If you partner has low sperm count, you also may have a blocked tube. Women who do not ovulate can also have endometriosis. Some men think that their female partners are infertile due to a female factor while they also have subtle sperm abnormality that prevents fertilization. Women sometimes think their male partners sperm is abnormal while they also have low egg reserve and low egg quality. Couples potentially have a dual infertility factor, most of the time. Most notably, low egg number and quality should be considered in any couple seeking fertility evaluation and treatment. Even young women with good egg reserve have abnormal eggs.

Irrespective of infertility factors, consideration of other general factors e.g genetic screening results can have a significant impact on choice of fertility treatment modality. If both partners are carriers for cystic fibrosis, they may require embryo testing (PGD) in the setting of IVF as opposed tosimilar couples without this genetic risk factor.

Do not Accept Treatment Before a Complete Workup. Do not Accept Empiric Treatments

For that reason, no assumptions about fertility factors and treatment should be made before a completed workup for sperm, ovulation, ovarian reserve, Fallopian tubes and general factors (genetic and preconception screening). This careful and deliberate testing is unfortunately not always followed. In many cases, couples are treated with empiric treatments. Here are two very common empiric treatments commonly prescribed

a. Clomid used for everyone. Clomiphene is suitable as initial treatment for women who do not ovulate due to polycystic ovary syndrome (PCOS), have open tubes and normal sperm analysis. In modern reproductive medicine, clomid should not be used without testing of male and tubal factor. Clomid also should not be used in older women that ovulate regularly. The majority of these women are older and do not get pregnant because of lower egg quality. They require superovulation (more than one eggs) to compensate for lower egg quality.

b. Progesterone supplementation. Low progesterone can cause early miscarriage (not infertility) in a small percentage of women. Women that yield low progesterone after ovulation do so because of abnormal development of follicles. They are better served by induction of ovulation to produce better follicles, rather than progesterone supplementation. During fertility treatment, progesterone levels are monitored and maybe supplemented if low. Progesterone treatment in itself is not a treatment for any form of infertility.

c. Laparoscopic surgery for endometriosis. The magnitude of benefit for surgical treatment of infertility associated with endometriosis is limited and maybe harmful. Laparoscopic surgery for severe endometriosis is risky e.g bowel injury. Resection of endometrioma can reduce ovarian reserve. IVF is a better than laparoscopic surgery in treating infertility due to moderate and severe endometriosis . The increase in pregnancy rate after excision of mild endometriosis is limited (probably 30 surgeries are needed to produce one newborn).

d. Varicocele repair for male factor infertility. Although sperm parameters may improve after varicocele repair, there is no conclusive evidence that it will translate into higher odds of pregnancy in female partners. There is a limited indication for varicocele repair aiming at improving fertility in males.

Many of these empiric treatments and prescribed with no or limited scientific basis and represent bias and expertise of the prescriber.

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How to Select an Egg Donor

How to Select an Egg Donor

How to Select an Egg Donor

Egg donation entails the fertilization of eggs of a young woman and transfer of the resulting embryo or embryos into the intended mother uterus. In the majority of cases, women are interested in egg donation when their ovarian reserve is diminished in quantity and quality, commonly after multiple unsuccessful IVF cycles. The eggs of young women are usually high in quality making the chance for pregnancy and delivery very high. Women can select an egg donor from one of two pools

Egg Donors

Egg Donors

Eggs from a Live Donor

An young woman is selected for donation, her ovaries are stimulated then eggs are retrieved. Two types of egg donors exist:

   i. Known Egg donor

The egg donor is known to the intended mother. The donor could be a related e.g. sister or not a relative but agreed to open identity egg donation.

   ii. Anonymous Egg donor

The egg donor is not known to the recipient. The majority of eggs donated are contributed by anonymous donors. If you select a closed identity donor you will still be able to know a great deal about her as age, ethnicity, religion, education, medical and family history, prior donations, physical features, childhood or even adult photo. Anonymous egg donors are usually recruited by a third party: IVF clinic or an egg donation agency.           Shared Donor cycle: Sometimes the eggs from one donor are shared between two recipients to reduce cost. Sharing however may yield lower chance for pregnancy per couple.

Donor Egg Bank

An egg bank will recruit the donors, stimulate their ovaries and freeze them. Recipient select from an already frozen inventory. The advantage is that they do not need to wait for a donor to be found, tested and her eggs harvested. In addition it is cheaper because only some of the eggs resulting from stimulation are obtained and no expenses incurred for donor travel and accommodation. On the other hand, it may yield lower chance for pregnancy (eggs are frozen and fewer of them are available). Donor selection is also restricted to available inventory of eggs that were already donated at an earlier time.

Results of Donor Egg Cycles Based on Donor Selection

Based on hundreds of thousands of donor egg cycles some general expectations of pregnancy and live birth rates can be made:

a. Anonymous cycles usually yields a higher pregnancy rates than known donors. Anonymous donors are selected on pure medical grounds first. They tend to have better ovarian reserve and are commonly younger than known donors. Many times known donors are based on other grounds e.g sister donor or a friend that will donate without compensation

b. Donor egg cycles distributed to one recipient are more successful than those shared between two recipients due to more eggs and embryos being available for selection and transfer.

c. Fresh eggs from live donors produce more babies than frozen donor eggs. A study of 11,148 egg donation cycles performed in 380 U.S. clinics in 2013, including 2,227 that used frozen eggs indicated that

for each IVF cycle the live birth rates were 50% with fresh eggs, and 43% with frozen eggs and

for each embryo transfer, 56% of embryos created with fresh eggs resulted in a live birth, compared to 47% of embryos created with frozen eggs.

The Process of Selecting an Egg Donor

The process of selecting an egg donor is complex that involves you, your partner, your reproductive endocrinologist and sometimes other parties. The guiding principals for selecting a donor are

a. Selecting a donor with good ovarian reserve    b. Protecting the mother from the transmission of infectious diseases   c. Protecting the babies from the transmission of genetic diseases   d. Protection of the egg donor from potential complications of IVF   e. Partners preferences.

Ovarian reserve: an egg donor should have an excellent ovarian reserve. This predicts excellent response to treatment with fertility medications and the collection of large number of mature goo quality eggs. Egg reserve is assessed through history taking, vaginal ultrasound estimation of antral follicle count, day 3 FSH and estradiol assay and AMH levels. Donors should be younger than 32 years and preferably younger than 30.

Infectious disease screening: donor are screened using first a thorough history and examination. Donor practicing in high risk behavior and those that lived in certain geographical areas are excluded. Lab tests are obtained for hepatitis B, hepatitis C, HIV I/II, Syphilis, gonorrhea and chlamydia. Other tests for infectious diseases could include testing for human T lymphocyte virus I/II, West Nile virus and South American trypanosomiasis. Tests are run at initial encounter then repeated in specialized labs within 30 days of retrieval to minimize the possibility of acquiring any of these infections at a later time.

Genetic screening: Extensive genetic and family history is first obtained from the donor. This is followed by screening for at minimal cystic fibrosis and any genetic disease related to donor ethnicity e.g hemoglobin abnormalities in African, Asian and Meditranean donors-Ashkenazi pannel in Jewish donors. Spinal muscular atrophy and fragile X syndromes are commonly also screened. More recently a universal genetic test that include 100 most common genetic diseases is routinely used. If an abnormality is found, a genetic counselor is consulted.

Donor related precautions: Egg donors should have the ability and intelligence to understand the process. This is evaluated by a trained psychologist. egg donors are counseled that the process does not impair their ability to conceive children of her own. Stimulation is tailored to avoid excessive stimulation and ovarian hyperstimulation syndrome. Donor are followed up after the procedure to monitor for any complications form retrieval and that the ovaries regained their normal size after stimulation.

Partners preference: Partners are offered a session with a psychologist to express their feelings about the process and to discuss some of the early and long term aspects of the process inducing legal issues an disclosure to children when they reach maturity. Partners may prefer certain race or ethnicity e.g Asian, Jewish…Some agencies specialize in recruiting donors of specific demographics. Physical features are also strongly considered and discussed with couples. Academic achievements are also desired by many couples.

Other considerations: Male partner sperm analysis and labs are obtained. The mother is assessed for any medical disorder and the ability to carry a pregnancy safely. The uterine cavity is evaluated using hysteroscopy or saline sonography. The endometrium is evaluated for its response to hormones. The cervix is mapped to avoid difficult embryo transfer.

The process of egg donation is commonly satisfying to recipients, donors and physicians and is flexible to allow for safe selection of an egg donor and still consider your preferences and aspirations.

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Testosterone Therapy-Male Infertility

Testosterone Therapy-Male Infertility

Testosterone Therapy-Male Infertility

Many men are prescribed testosterone for a variety of reasons. Low testosterone levels (Low T) with no symptoms, general symptoms of low energy and feeling  tiered and sexual symptoms, among others. Approximately 2.5 million men are prescribed testosterone each year in The US, mostly with no proper testing. Testosterone is only approved by FDA for low testosterone associated with specific diseases affecting testicular function.  The FDA recently issued a safety communication cautioning the use of testosterone replacement for low testosterone levels and requiring labeling change to inform men of a possible increase in side effects.

From the fertility standpoint, there is no role for testosterone treatment, that could be detrimental. There is also no proven role for other medical treatment as clomid, letrozole, nolvadex, hCG and others in enhancing fertility in the vast majority of men

Effects of testosterone on male fertility

When men are prescribed testosterone, sperm production slows down significantly and may completely stop. Many of them, no sperm can be found in the ejaculate (azospermia). Testosterone therapy can markedly lower the ability of men to father children. Testosterone inhibits a key master gland hormone (FSH) that is required to stimulate spermatogenesis (making sperm). The specific effects of testosterone on sperm count are unpredictable. In some men sperm count drops to zero even after a short use of testosterone.

Interestingly, when testosterone is stopped some men but definitely not all of them recover sperm production, commonly in one to six months. The extent of the recovery of sperm count is also unpredictable. The recovery of sperm count maybe limited requiring fertility treatment for conception to take place. A short course of testosterone can lead to a low sperm count for a very long time.

What can be done about low sperm count related to testosterone treatment

In addition to evaluation of female factors especially ovarian reserve, always a priority, men on testosterone and showing low sperm count should be advised to

1. Stop testosterone administration immediately

2. Repeat sperm analysis in 2 months. Sperm analysis should be performed in a facility that can perform diligent search for even very few sperm and  can freeze sperm. If sperm is found in the ejaculate it should be cryopreserved immediately. If no sperm is found then sperm analysis should be repeated in another 2 months. The wait for recovery cannot be indefinite because of further deterioration of ovarian reserve in female partner with time.

3. Depending on the extent of recovery sperm can be utilized to promote conception. If sperm count recover close to 10 million moving sperm, natural conception can take place. Also sperm can be used for IUI, if needed. If the number of motile sperm is significantly lower, IVF is required, sometimes with intracytoplasmic sperm injection (ICSI).

4. If still no sperm were found after repeat analysis, TESE (testicular sperm extraction) can be attempted. A male reproductive urologist can perform diligent search for areas of spermatogenesis in the testes through repeat minute biopsy and searching under the microscope.

From the preventive aspect, avoid testosterone treatment if you intend to father children in the future. Know that there are very few solid indications for testosterone. If testosterone treatment is inevitable, consider pretreatment sperm freezing. Use gel preparation preferential to injection as they are not stored for a long time in the body.

Testosterone treatment is a preventable cause for infertility in males and could be detrimental to future fertility.

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Ten Reasons why You Should not Use Clomid for Fertility Treatment

Ten Reasons why You Should not Use Clomid for Fertility Treatment

Ten Reasons why You Should not Use Clomid for Fertility Treatment,

Not the Way your Using it Anyway

Ten Reasons why You Should not Use Clomid for Fertility Treatment, Not the Way your Using it Anyway. Clomiphene citrate (clomid) was the first medication introduced for fertility treatment (1960s). It works through masking of estrogen receptors in the brain. The brain, blind to estrogen in the blood, starts pouring FSH, the protein that drives development of dormant follicles in the ovary.

When one considers a fertility treatment: not only the pregnancy and delivery rates per cycle is considered, but also the time to conceive (TTC) and the complication rate especially multiple pregnancy. Clomid is a very attractive medicine to women and gynecologists, alike. It is an oral medication, easy to use for both general gynecologists and women seeking fertility treatment. It is also cheep. It is successful in inducing ovulation in 90% women that do not regularly ovulate e.g. polycystic ovary syndrome. Response to clomid is modest in most cases (1-2 follicles).

In spite of all these advantages, there are many other disadvantages. It, most likely, will not improve the odds of conception in regularly ovulating women. Its indiscriminate use, in The US and worldwide (without ultrasound monitoring of ovarian response), probably makes clomid the drug responsible for multiple pregnancies over all other forms of fertility treatment. Although clomid is successful in inducing ovulation in 80-90% of well selected patients, only 20% become pregnant. This discrepancy happens because of undesirable effects of clomid on the lining of the uterus (thin) and cervical mucus (thick). In my opinion though, many clomid cycles fail due to its in women that are not destined to benefit from it. Those are older and regularly ovulating women with unexplained infertility as opposed to suitable candidates: younger non-ovulating women. Clomid offers little help to women with unexplained infertility (ovulating) because in these women, the majority do not conceive because of chromosomal abnormalities in the eggs. Clomid commonly does not induce superovulation (many follicles) to partially compensate for abnormalities in the eggs.

Do Not Use Clomid Unless

1. Preconception labs are normal. Many patients are prescribed clomid without a complete fertility workup, including genetic screening. If you and your partner are carriers of cystic fibrosis or sickle cell anemia gene abnormalities, for example,you are at risk of transmitting these diseases to your future children (1:4). Genetic screening should be performed BEFORE starting fertility treatment. It does not help you to detect these abnormalities after pregnancy ensues. Decline clomid or any other fertility treatment without proper preconception history and lab tests.

2. Evidence of patent tubes. After ovulation induction, using clomid, the eggs has to be picked up by the fallopian tubes. Sperm also has to enter the fallopian tube to allow fertilization. Completely blocked fallopian tube may prevent the egg and sperm to meet. Partially blocked fallopian tube may allow fertilization but the the embryo may become stuck in the tube leading to ectopic pregnancy.

3. Near normal sperm analysis. A sperm concentration of < 15 million per mL and movement < 50% may reduce the odds for fertilization and reduce the chance of pregnancy after clomid treatment.

4. If you ovulate regularly. Together with normal sperm analysis and open tubes, that indicates you have unexplained infertility. The most likely cause for not conceiving is chromosomal abnormalities in the eggs. We cannot fix chromosomal abnormalities if the egg but we can induce the ovaries to produce more eggs. More mature eggs means more chance of producing a normal egg. Clomid induces the ovary to produce 1-2 eggs in most cycles, thus does not address effectively egg abnormalities. On the other hand, if you are young and do not regularly ovulate, clomid is able to induce ovulation and potentially solve your problem.

5. Without monitoring. Some women are more sensitive to the effects of clomid. They respond by producing a large number of follicles. The safest approach here is to cancel the cycle and restart another treatment with a lower dose. Although the risk of multiple pregnancy with clomid is about 10%, women that respond with producing a large number of follicles are at a much higher risk. Careful monitoring of response, using vaginal ultrasound, is required in all clomid cycles.

6. Use the lowest dose that leads to ovulation (start with one tablet per day). Do not increase the dose if ovulation took place at a lower dose. Most patients get pregnant at adoses of 50 to 150 mg (1-3 tablets) per day. Increasing the dose does not increase the chance for pregnancy and increases the side effects of clomid e.g thin endometrium, chick cervical mucus..

7. Do not use clomid more than 3 months (6 months life time max). The majority of women get pregnant in the first three months of treatment. If you are younger and ovulate on clomid and would like to try few more months, then 6 months is the maximum amount of time you should use clomid in your life time.

8. Clomid less likely to lead to pregnancy  delivery in women >38y. In women 38 or older with unexplained infertility, there is good evidence that clomid-IUI is inferior to IVF. The vast majority of women in that age group that start on clomid end up switching to IVF to achieve pregnancy.

9. Expertise with optimizing clomid cycles: clomid cycles should be supervised by a physician with expertise in clomid dosing, use of repeat courses, use of adjuvant treatments as estradiol and IUI. This enables maximizing the benefits of fertility treatment and tailoring treatment to individual woman.

10. Use letrozole before using clomid. Accumulating evidence from many studies, including randomized clinical trials, indicates that letrozole is superior to clomid in terms of achieving pregnancy. Applying the same principals above, letrozole should be considered as the initial treatment for anovulatory infertility.

On tailoring Fertility Treatment to Specific Patient’s Needs

In too many times, the use of clomid for fertility treatment is a stark example of tailoring patients to treatments familiar to general gynecologists, rather than individualizing fertility treatment to women biology and fertility needs, citing ease of use, perceived safety and familiarity. Cheep treatments that appear safe can quickly become aggressive and unsafe if they lead to low pregnancy rate and high multiple pregnancy. The time lost treating older patients with clomid for a prolonged periods can be detrimental to their ovarian reserve and can minimize the chance for eventually achieving pregnancy and delivery.

On men and clomid

There is no proof that men benefits from the use of clomid and similar treatment to improve sperm parameters. Specifically, there is no evidence that female partners of men that were prescribed clomid conceive at higher rates. With very few exceptions, clomid should not be used to treat male factor infertility.

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