Clomid (Serophene) became commercially available in 1968 and is the first choice in ovulation induction for most women because of its effectiveness and low cost. Clomiphene citrate is similar to estrogen, but its predominant role is that of an anti-estrogen.
Clomiphene citrate stimulates increased levels of Follicular Stimulating Hormone (FSH) and Luteinizing Hormone (LH) eased levels of FSH and folate stimulate the follicle and lead to ovulation. Clomiphene citrate is used to stimulate ovulation, increase ovarian progesterone secretion during the second half of the cycle, and make cycle lengths more predictable.
In women without menstrual cycles, an initial course of clomiphene citrate is started after a progestin (Provera) induces a period. The patient is instructed to take clomiphene citrate for 5 days after her period.
In general, an ultrasound is performed prior to initiation of clomiphene citrate in order to ensure that this medication can be given safely. Women occasionally have an ovarian cyst, which may prevent the use of clomiphene citrate during that cycle secondary to possible negative effects of the cyst on ovulation. Intercourse should begin 3-5 days after the last clomiphene citrate tablet every other day for approximately 1 week.
In women with spontaneous menses, clomiphene citrate may be started on days 3-5 of the menses. Ovulation predictor kits detecting LH surge may demonstrate false positives if testing during the month of clomiphene citrate administration.
In general, a cycle-day 21 progesterone and ultrasound are performed to document whether ovulation has occurred. If not, a progestin withdrawal bleed is induced with Provera. The dose of clomiphene citrate is then increased up to a dose of 150 mg per day. If ovulation does not occur, gonadotropins are added to the ovulation induction regimen in combination with Clomid.
Once the patient ovulates, we wait to see if she conceives. If she does not, the same dose of clomiphene citrate is given after a normal pelvic sonogram. Clomiphene citrate can result in residual follicles or cysts persisting into the subsequent cycle. If these cysts are present, clomiphene citrate should not be taken until they have resolved.
If the patient has not had a hysterosalpingogram (HSG) and the husband has not had a semen analysis after at least the first dose of clomiphene citrate is utilized, these are ordered at this time. Once a dose of clomiphene citrate causes ovulation, the dose is maintained. Approximately 83% of women who become pregnant with clomiphene citrate do so within the first 3 cycles. Therefore, in general, clomiphene citrate is not given for more than 3 cycles before considering other options such as ovulation induction and insemination.
The more common side effects of clomiphene citrate include flushing during the time of ovulation citrate administration. Occasionally, ovulation pain is noted since this medication is used for ovulation induction. There is also increased ovarian sensitivity around the time of ovulation. If visual complaints are present, clomiphene citrate is discontinued.
Other side effects of Clomid include:
This may make it more difficult to conceive since cervical mucus is necessary in order to aid sperm penetration into the uterus. If this is a problem, the best treatment is to perform intrauterine insemination.
Another common side effect of clomiphene citrate is poor development of the endometrium. If the endometrium is less than 7 mm in thickness, pregnancy may be more difficult and other treatment options should be considered.
The incidence of twins is increased by 5-10%, but multiple births of more than twins are rare. The rate of spontaneous abortion is not increased, nor is there an increase in congenital malformation.
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