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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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Should you Consider Fertility Assessment when you do not Intend to Get Pregnant Soon?

Should you Consider Fertility Assessment when you do not Intend to Get Pregnant Soon?

If you do not intend to become pregnant in the near future, do you need to assess your fertility? It is very possible that many women and men will be screened for relatively a small number of individuals that will show abnormalities. From the individual point of view, however, there are two distinct potential benefits:

Detection of abnormalities related to fertility and reproduction:

consider fertility screening if you intend to delay pregnancy or knon fertility issue

Screening for fertility problems

Ovary: Diminished ovarian reserve and anovulation

Fallopian Tubes: tubal block

Male factor: abnormal sperm analysis

Other factors: abnormalities of the uterus or cervix

Detection of abnormalities related to the safety of getting pregnant:

Screening for genetic abnormalities: carrier screening

Screening for other medical disorders and infectious diseases

The decision to consult with a reproductive endocrinologist to assess your fertility is individual. One would be more interested in fertility consultation in the presence of

1.  Known Fertility Issue: PCOS, absence of menses, endometriosis, fibroids, PID, abdominal surgery, prior chemotherapy for cancer or lupus

2. Risk factor for low fertility: 35 years or older and intend to delay pregnancy

3. Genetic or medical risk factor: genetic screening especially in certain ethnic groups e.g Ashkenazi Jewish individuals

Informed about your fertility potential you may elect to either do nothing or respond to the abnormal results. If diagnosed with lower ovarian reserve you may elect to attempt pregnancy sooner or freeze your eggs. If a genetic abnormality is found in both partners you may consider testing of embryos to avoid transmission to the babies. If an abnormal sperm parameters were found, a referral to a urologist and / or sperm freezing could be considered.

There are no clear cut recommendation for fertility screening in men and women not intending pregnancy in the near future. Women intending to delay getting pregnant or with a known fertility issue and certain ethnic groups should consider screening for fertility and genetic problems.

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Letrozole vs Clomid for Ovulation Induction in PCOS

Letrozole vs Clomid for Ovulation Induction in PCOS

Letrozole vs Clomid for Ovulation Induction in PCOS

Polycystic Ovary Syndrome (PCOS) is associated with two of the following criteria:

a. No ovulation (anovulation) or less frequent ovulation

b. Hign male hormone (androgen)

c. Polycystic appearance of the ovaries: large number of small follicles

Clomid is an oral medication that modulate or mask the estrogen receptor leading to release of internal FSH from the brain

Polycystic Ovary

Polycystic Ovary

Letrozole is an oral medicine that reduces estrogen production from the ovary through antagonizing the function of the aromatase enzyme, responsible for making estrogen. The brain respond by releasing FSH.

Which one is better?

In a recent good quality study, 750 infertile women, aged of 18-39 years, with a diagnosis of PCOS were studied. The women were randomly allocated to CC vs. letrozole for 5 treatment cycles. CC 50mg every day for 5 days (days 3-7 of cycle), or B) letrozole 2.5mg every day for 5 days (days 3-7 of cycle), for a total of 5 cycles or 25 weeks. The dose will be increased in subsequent cycles in both treatment groups for non-response or poor ovulatory response up to a maximum of 150 mg of CC a day (×5 days) or 7.5mg of letrozole a day (×5 days). 27.5% of women who received letrozole (Femara) had a live birth, compared with 19.5% of women treated with clomiphene. One quarter were clomid resistant and never ovulated.

Letrozole was associated with lower multiple pregnancy rates.

Letrozole appears to improve live birth and pregnancy rates in subfertile women with anovulatory PCOS, compared to clomiphene citrate.

Letrozole should be considered as a first line agent for induction of ovulation in women diagnosed with PCOS.

In general it is adviced that oral medication are tried first in PCOS before proceeding to injection medications (gonadotropins). Gonadotropins induce multiple ovulation and increase the risk for multiple pregnancy. If oral medications fail to induce ovulation or no pregnancy ensues, it is preferable to proceed to IVF with single embryo transfer and not injectable medications – IUI to avoid twins and higher order multiple pegnancy.

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