Tuesday, May 24, 2011

Clomid Protocol In Depth: Dosage, Specific Indications & Period Of Use

Hello Doctor,

Your willingness to answer fertility questions is admirable. Let me say, "Thank you!"

I've been trying to find specific information on your blog regarding clomid protocol and I simply cannot find what I'm looking for. I do find questions and answers regarding clomid, but not specific information on how and when to use it, for how many months etc. Do you have a specific link perhaps? Thank you again, J. in the USA


Hello J. from California,

Actually the answers to those questions are in the blog but are within the body of the answers. I don't think I have one entire blog post that goes over the specific indications or period of use. You can look at my website for more information as well: "Ovulation Induction".

I will endeavour to explain as much as I can here:

Clomid is one of many medications that are used to induce ovulation. In most cases it is used for patients that have an ovulation disorder, i.e. don't ovulate spontaneously or have a hormonal imbalance leading due to an ovulation disorder. Clomid is an estrogen that blocks the estrogen receptor and induces the brain to increase the FSh output thereby stimulating the ovaries harder. Some doctors will also use Clomid, and other fertility medications, to "superovulate" the ovaries. That is to increase the number of eggs that the ovaries give off so that the chances that an egg with reach, enter and get fertilized will be increased. Unfortunately, many doctors use this as their "magic pill approach" to infertility and will prescribe it without doing an infertility evaluation or determining whether or not it is indicated.

In my blog, I go over how the Clomid is given and how I recommend doing a Clomid ovulation induction. But as a basic method, Clomid can be given in doses ranging from 50mg per day to 250mg per day (1-5 tablets). It is taken orally once per day for a five day period. Most Physicians will give it between cycle day #3-7, 4-8 or 5-9, with cycle day #1 being the first day of the period. It should be taken at approximately the same time of day each day but the specific time is not critical. Most textbooks will state that you should start with the lowest dose of Clomid and increase the dosage in 50mg increments per month if the patient does not respond to that dose. Many doctors blunder by increasing the dosage anyway if the patient does not get pregnant in that month, thinking that a higher dose increases the chances of fertility. That is not true! It only risks increasing the number of eggs that the patient ovulates and therefore the higher chances of a multiple pregnancy.

In essence the lowest ovulatory dosage should be used, so that if a patient responds to 50 mg with ovulation, then you stay at that dose. If ovulation does not occur, then it is increased by 50 mg. I don't quite follow this method because as you can see, if the patient does not respond to dosages less than 250mg, then you have wasted four months finding that out. Instead, my experience has shown me that it is better to be more aggressive and quicker in finding the dose that the patient responds to or to know whether she will respond at all. For example, the most common patients that require ovulation induction are PCO patients. I don't start at 50 mg. Rather, I start at 150mg then proceed to 250 mg if they don't respond. If they don't respond to 250mg, then I know that we have to move to stronger meds. This is because most PCO patients will require high dose Clomid or will not respond to Clomid so I want to find out as soon as possible. In a patient being superovulated, you have to use doses lower than 150mg because these patients are already ovulating. I use superovulation mainly in older ovulatory patients (over 35 years old) because I know that one problem they are facing is an egg quality issue and increasing the number of eggs does in fact increase their chances. I will often strive to get them to ovulate up to 5 eggs per cycle. Finally, I don't recommend more than 6 ovulatory cycles of Clomid. If you have not achieved pregnancy by then, then there is something else going on and so you have to move to a more aggressive treatment plan.

I hope that this answers your questions.

Good luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.

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