The Wrong Way To Do A Clomid Induction Cycle

Question:

Hi. My Doctor prescribed me provera to induce a period and then clomid to induce ovulation. She told me that monthly I am supposed to take provera from the first of the month through the tenth of the month and then once my period comes i'm supposed to take Clomid from day 5-9.

So here it is, May 13th and it is day two of my cyle which means I will take Clomid May 16th-20th. Am i supposed to automatically take the Provera again on the 1st of June? That just doesn't sound right to me. Please help me understand this. C. from Nevada

Answer:

Hello C. from the U.S. (Nevada),

You are wiser than your doctor, which means you are seeing the WRONG doctor. She is not correct on the proper method to do a Clomid ovulation induction cycle. I would recommend that you look up my blog and review how I recommend doing Clomid cycles. I think you will be shocked once you compare it to what your doctor prescribed!

First, Clomid cycles should be monitored for three reasons: (1) to see whether you are responding to that dose of Clomid (there are five dosages that can be used). (2) to see how many follicles are developing so that you don't have too many and (3) to determine when ovulation is going to occur so that you can time your intercourse properly.

The "autopilot" method of Clomid ovulation induction is not correct and shows that your doctor has a very limited knowledge of this treatment and infertility in general. I would strongly recommend that you go see a fertility specialist so that you don't waste your time.

Many doctors will use a progesterone supplement with Clomid cycles in order to support implantation and the early pregnancy. Clomid often can induce a luteal phase defect. However, Provera is NOT the drug used because it is a synthetic progesterone. Instead, a natural progesterone like Prometrium is used and a pregnancy test is done at the end of the cycle to determine whether or not your are pregnant so that you can stop the medication and have a period. If there is a luteal phase defect and you stop the progesterone prematurely, that could induce a miscarriage due to inadequate progesterone support. Does that make sense? So you can see why your doctors orders are all wrong.

Good Luck,

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

Secondary Infertility With Miscarriage And Possible Luteal Phase Defect: Is Clomid OK?

QUESTION:

Hi Dr. Ramirez. Here I am writing again. I previously emailed you, I had a miscarriage in Feb 2010, at about 7 weeks. I have a 4 year old and a 3 year old, conceived the first month I tried with both. I also got pregnant the first time with the miscarried pregnancy. Since March I have been trying to get pregnant and nothing has happened. I have been getting my period every 25-27 days, and the last 2 months I have been doing BBT charting so I am pretty sure I am ovulating. I had hormonal blood work done in June and another estrodial draw in July and all were within normal range, Although the estrodial was a little low.

I had an HSG procedure last month; normal tubes and uterus. Now we have to have my husband's sperm checked. It has been 8 months now and for the last 6 weeks I have been having acupuncture/taking chinese herbs, to strengthen my uterus and help me relax. I have told you before that my periods are shorter and lighter since the loss, the tend to start and stop and the flow is very limited. My obgyn has now suggested that I start a low dose clomid to see if that will help me.

I have read your blog and I understand that you do not agree with clomid for people that already ovulate on their own. I am wondering if you think I should see a specialist. Also, since I have started charting I have noted that my cycle last month was just 25 days, and from the temp drop indicating ovulation to the start of my next period was only 9 days (luteal phase). This month the luteal phase was 11 days. My obgyn said that the way they would help that would also be through clomid. I thought, from reading your blog that progestorone is only suggested. If I start the clomid, do you think I should also ask for estrogen since my period is so short.

I am trying to relax doctor, but I am worried that I won't be able to get pregnant again. I am 31 years old. My husband is 38. Thanks in advance for your time and advice. J. from the U.S.

ANSWER: Hello Again,

Thank you for following my blog.

I think you misunderstood a little. I don't disagree with ovulating patients using Clomid, I just don't like docs who turn to that immediately in ovulating patients without having done a full infertility evaluation. There certainly is a place and time to use Clomid in ovulating patients, and we call that "super-ovulation". I use this especially is older patients to help them ovulate more than one egg at a time to increase there chances because as a woman ages, more and more of her eggs are debilitated and poor quality. By increasing the number ovulated, you increase the chances of getting a good egg.

In your case, even though you are ovulating, your luteal phase is too short. It is likely that you have a luteal phase defect. Your doctor is correct that Clomid can correct a luteal phase defect, although not always. What it does is correct the ovulatory-hormonal problem that is leading to the LPD. In addition, by getting you to ovulate more than one egg, it increases your chances for a pregnancy with each cycle. But, because it doesn't always correct the LPD, the treatment of choice would be supplemental progesterone such as Crinone, Procheive, Prometrium or Endometrin. You would start that after ovulation.

If you continue to fail to conceive, my recommendation would be to see a fertility specialist, instead of undergoing treatment that is more of a "shotgun" treatment. That way you don't waste too much time. But if you want to try some low dose Clomid with your current doc, that would be okay too. The advantage you have is that you are still young. If the low dose Clomid does not work, or your doc is not doing the cycles correctly, then definitely go see a fertility specialist.

I don't think you need supplemental estrogen.

Follow Up Question (Sometimes Great Things Happen When You Least Expect!):

Hi Dr. Ramirez,

I just wanted to repost and thank you so much for all your help and advice in taking the time to answer my questions over the last several months.Your answers to my questions and that of many others have always been honest, reassuring and optimistic. I never got to take the clomid, I was supposed to start January 2011, but with prescription in hand, I instead bought a HPT and I am now 10 weeks pregnant! So yes, a bit more patience and relaxation helped...9 months after my miscarriage I am pregnant. I saw the heartbeat at 6 weeks 7 days and again at 9 weeks 3 days, so I know we are not in the clear yet but we are headed to 12 weeks!

My OBGYN said that once you see the heartbeat, there's a low chance of loss. I am also taking prometrium (spelling) progesterone by mouth. My levels were good in the beginning, but my doc is just being safe with me. Is around 10 weeks gestation the time you have your patients stop taking them? Just wondering what your protocol was.

Thanks again! Keeping my fingers crossed that everything will go smoothly this time around!

J. from the U.S.

Follow Up Answer:

Hello Again,

Thank you for the kind words and CONGRATULATIONS! Once the pregnancy reaches 8 weeks and the size is appropriate for dates and the heart rate at 120 or higher, the chances of a miscarriage drop to 5% (from 40%). So, you are in a very good position for this pregnancy to keep going.

One thought: Studies have shown that progesterone (prometrium) orally does not help with luteal support. Too much of the chemical is lost in the liver. For that reason it is usually used vaginally. I usually will stop it at exactly 10 weeks gestational age, but some clinics will keep going until 12 weeks. By 10 weeks, the placenta has taken over so it doesn't do much. I think the extra time is for peace of mind.

Good luck with the pregnancy and congratulations again.

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Comment: Excellent source of information from Dr. Ramirez. Highly value his thoughts and advice!

Alaskan Worried After First Miscarriage: Was The Cause Low Progesterone? No!

Question:

Hello, I am writing to you from a remote community in Alaska,

We have a clinic and Doctors here but, no hospital or specialists, so I am glad to have found your site and hope to receive an answer to my concern. I suffered a miscarriage on Jan 10th at 8 weeks. For the year leading up to my pregnancy I had mid cycle bleeding starting around 7 DPO. I now believe that I bled and lost my pregnancy due to low progesterone.

My MD here in town tested my levels on days 10-12-14 post ovulation and the results were 7.8 - 17.9 - 20. She says these are all normal and I can try again, but everything I see online says the numbers are in fact low and supplements should be started after I ovulate next. I also have been BBT charting and my temp drops to pre ov levels within 2 days of the ovulation spike and stays low. Do you see a low progesterone issue here and would you recommend suppositories? Please respond as I am so confused and somewhat upset that the info I am getting from my Doc. does not match the info on the web. Thank you so very much for taking the time to consider this.

I appreciate it more than you know. S. From Alaska, USA

Answer:

Hello S. from Alaska,

Thank you for writing me with your concerns. Progesterone levels measured at the mid-luteal phase do not make the diagnosis of luteal phase defect. They are mainly used to confirm ovulation. Any level above 10 confirms ovulation if the test is done in the mid-luteal phase (CD#20-22). In order to make a diagnosis of luteal phase defect, an endometrial biopsy would need to be taken at the end of the cycle to check for endometrial dating. This is usually done around CD#26-28 (before your period starts).

Progesterone is such a simple treatment with no side effects and much benefit that I do not see any harm from using it after ovulation. We certainly use it with every type of fertility treatment that we give. There are two that are made specifically for infertility treatment called Crinone and Endometrin. Another one that is used is called Prometrium but is not specifically for infertility use. You would start the supplementation on cycle day #16 and continue until a pregnancy test is done at the end of the month. Do not stop the medication until a pregnancy test is done and do not wait for a period because the progesterone will likely prevent that from occurring. If you are pregnant then you would continue it until you are 10 weeks gestational age.

Now with all that being said, a lack of progesterone is NOT the reason why you miscarried. The placenta takes over progesterone production at the 6th week so a luteal phase defect or lack of progesterone would not cause a miscarriage at that point. It is usually earlier. The most common reason for a miscarriage in the first trimester is a spontaneous chromosomal defect that occurred at the time of embryo division. This led to an abnormal embryo, which the body detected and stopped. It is most likely that you will have a successful pregnancy subsequently.

You have to take the information you find on the web with a very large grain of salt, and don't try to micro-interpret what may or may not have happened or is happening. Since you were able to get pregnant naturally before, you chances of a successful pregnancy are high. We don't worry about recurrent miscarriages until there have been at least three consecutive miscarriages. Keep trying!

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Patient With Short Luteal Phase Has Spotting With Progesterone Suppositories, Is This Normal?

QUESTION:

Dr. Ramirez, I am hoping that you can help answer some questions for me as I am feeling confused and hopeless...I am 30 years old and I am trying to concieve. I was on the birth control pill for 9 years and stopped taking it in June. I have been charting my Basal Body Temps and discovered that I have a short luteal phase--

I begin spotting 9 days after ovulation and start my period the following day making my luteal phase 9-10 days. My period is very light-- only lasting a few days. I have been taking Vitamin B6 supplements and my doctor started me on Crinone Progesterone Suppositories this month. I began 3 days after ovulation and am taking 90mg once per day.

Yesterday, 9 days into my luteal phase, I began spotting very lightly when wiping. This was very discouraging as I usually begin spotting on day 9 before starting the suppositories. I was convinced that I was starting my period as I had in previous months and that this was not implantation spotting due to the coincidence of the spotting on day 9.

However, now on day 10, I am wondering if I gave up hope too soon. The spotting is still VERY scant and does not seem to be increasing as in previous months. Also, the actual flow of the bleeding seems a little different than previous months. Upon intially wiping, there is no blood on the toilet paper. After wiping a couple of times, a very small amount of red blood appears on the toilet paper. In fact, as I continue to wipe, the bleeding seems to increase with each wipe. Also, it does not resemble my usual spotting (blood mixed with a wet discharge) but just small amounts of blood smears. The flow only appears when wiping.

Should the progesterone suppositories have increased my luteal phase count at least a little bit? It's very discouraging to think that there was no increase at all. If my period is beginning, does this mean that it is not a progesterone issue? What else could cause a Luteal Phase Defect? Can your period begin while you are taking the suppositories? I read online that your period will not begin until you stop taking the progesterone? However, I have also read conflicting info as well.

Could this be "break-through bleeding"? Is this common with suppositories? Could you explain what this is? Does this sound like implantation spotting? I called my Dr. and she said to stay on the progesterone for a few more days and see if my period does start. She has admitted that she is not too familiar with LPD isues and has referred me to a Reproductive Endocrinologist however the earliest appointment I could get is March. I am feeling really confused and discouraged. Any help, guidance or suggestions would be greatly appreciated! Also, I did take a pregnancy test today and it was negative but realize that it may have been too early. I am writing from Massachusetts.

ANSWER:

Hello D. from Massachusetts,

I have found that vaginal spotting is very common with the use of Crinone in my IVF patients, so I don't think you need to worry about it. Supplemental progesterone is the appropriate treatment for suspected luteal phase defect. A pregnancy test will be required because your natural period will not occur if you are on supplemental progesterone. The incident that causes the withdrawal bleed (your period) to occur is the abrupt drop of progesterone in your system if a pregnancy has not occurred. Therefore, I would recommend a scheduled serum bHCG at 14 days after ovulation. If it is negative, then stop the progesterone but don't stop until you have that result.

There are gynecologists out there that are well versed in infertility treatments. You don't necessarily have to see an RE for your level of care. You might want to call around and see if you can find one so you don't have to wait so long to undergo proper treatment. However, be very careful because there are many general Ob/Gyn's that say they do infertility that know very little and don't render proper care. You might want to ask them specifically how they diagnose and treat luteal phase defect. You also might want to find one that does IUI treatments, and avoid the ones that don't do this level of care.

Follow Up Question:

Thank you so much for your quick response! This was very helpful. It is encouraging to know that spotting is common when using Crinone. From your response, it sounds like my period will not start until I stop taking the progesterone. Do you feel confident that given the info that I provided that it is not my period starting and just due to the progesterone? Is this "break-through bleeding?"Also, do you think 90 mg once per day is adequate? I read about women taking the supplements 2 times per day. Again, thank you for any help you can provide and for your timely feedback. I appreciate your advice re: the RE as well. March seems like it will never get here!!

Follow Up Answer:

Hello Again,
I am confident that this bleeding is not your period, but keep in mind that there are always exceptions. It is most likely breakthrough bleeding as I explained previously. Crinone has been extensively studies for use in infertility and once per day is adequate.

I am happy to have helped clear up some of your fears. Good luck with your treatment and don't hesitate to write again!

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
Monterey, California, U.S.A.

The Importance Of Choosing A Qualified Infertility Specialist: 41 Year Old Patient Losing Time

(If the blog radio program turns on, please go to my October 1st post & pause it! I will be keeping the show up for the month of Oct.)

Question:

I have started evaluation with a RE at the beginning of August. I have so far been diagnosed as having low progesterone and not ovulating properly. I am just turned 41 and had a miscarriage at age 38 at 9 weeks.

My Dr said if my problem is only hormonal, it is an easy fix. He had me on prometrium for 10 days and now I go back for another ultrasound at the end of my menstrual cycle. I know other people have been put on Clomid with the prometrium. I just wondered what would be his justification or reason behind only giving me prometrium. I asked the nurse and she the prometrium was to help me ovulate. I am curious, I think my doctor is fabulous. I just want another opinion. Thanks! M. from the U.S.

Answer:

Hello M. from the U.S.,

I am glad that you wrote to me because your case disturbs me. You may like your doctor but he is wasting your time. If what you say is correct, neither he nor his nurse know what they are doing and they are leading you in the wrong direction!

If you ovulate correctly, then the progesterone level should be in the normal range. When that does not occur, it is called a "luteal phase defect" and the progesterone is used to help the endometrial lining of the uterus to convert correctly and support implantation. It DOES NOT cause you to ovulate. However, if your ovulation is not correct i.e. you are not ovulating, which would also lead to a low progesterone, then the treatment is to use a fertility medication to get the ovaries to ovulate properly, thereby correcting the problem.

There is another very very large issue, however, and that is that you are 41 years old. Did your "RE" talk to you about the age effects on your fertility? Did he tell you that your chances of a spontaneous natural pregnancy are only 1% per month or slightly less than 10% per year? Did he tell you that you may be wasting your time and possibly losing your ability to have a genetic child if you don't proceed in a more aggressive manner?

If your "fabulous" doctor is indeed an RE, then he should be very concerned about the impact of your age on your fertility and time. He would not be wasting your time with fruitless treatments like prometrium. He would be doing a more aggressive treatments like IUI (intra uterine insemination) or in vitro fertilization, IVF (preferred). Also, if he is indeed an RE, he would be doing IVF in his clinic. Does he? If not, then he may not be an RE at all.

My recommendation would be for you to go see a real infertility specialist, preferably one that does IVF, so that you can be counseled appropriately. I recently had a consult with a patient who, like you, went to a doctor that said that she was a fertility specialist. She was with this doctor from 36 years old to 45 years old. She was never referred to see a real infertility specialist, and so now, her only option is to use donor eggs with IVF. If she would have come to me sooner, we might have been able to get her pregnant using her own eggs. Please don't make that mistake!

Good Luck and keep asking those questions!

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Progesterone Supplement For Luteal Phase Defect

Question:

Hello Dr. Ramirez,

I am turning 34 later this month and have been trying to get pregnant for the past 4 months. I never have any spotting during the first half of my cycle, but have had light spotting usually for 3 - 5 days before my period starts (as long as I can remember except when I was on the pill). About 7 years ago my doctor did some tests and sent me for an ultrasound and when he found nothing wrong, put me on the pill to regulate this. I stopped using the pill about 3 years ago and have lived with the light spotting (starts very, very light and gets a bit heavier each day until my real period starts - usually starts on Day 27 to 32 of my cycle).

Over the last 4 months, I've been recording basal body temperatures while trying to get pregnant. I've noticed my temperature only stays high for about 8 days. It drops usually on the 9th day and the day after that very light spotting starts. After doing my own research, I'm concerned that I may have a luteal phase defect and need some sort of progesterone to help get/maintain a pregnancy. I went to my doctor and he said I would need to try for a year regularly before determining I have a fertility problem and he doesn't think testing is necessary yet even thought I think my temperature readings and spotting indicate there may be a problem. I understand it may take a while to get pregnant, but if there is a possibility of a problem that could be helped with progesterone, I would rather find out now than wait until next year when I'll be almost 35. Especially if I do need a referral to a specialist at some point, it could be a 6 month wait to get an appointment.

Does it sound like I may have a problem (hopefully treatable) or should I continue trying for another 6 or 8 months before undergoing any testing?

Thank you very much for your help, L. from Canada

Answer:

Hello L. from Canada,

I have had many letters from Canadians lamenting the fact that their Physicians are uncooperative and it is a long wait to see a specialist. You certainly have not tried long enough on your own to warrant an infertility evaluation, but I am surprised that you doc won't give you progesterone supplements. It is such a simple thing with no side effects and potentially helpful.

Yes, the BBT findings and pre-menstrual spotting are consistent with LPD. The diagnosis is made with an end cycle endometrial biopsy for dating. Since your doctor won't do that, we can make the assumption and you should go on progesterone supplements. There are many sources of natural progesterone. I believe you can even get natural progesterone creams in health food stores. I will usually prescribe the pharmaceutical versions such as Prometrium, Endometrin, Crinone or Prochieve. You have to take them starting from day #16, but the problem is that the supplementation may prevent your natural menses from starting because it is the dropping of the hormones that leads to a menses. So, you would have to do a pregnancy test to see if you are pregnant then stop the meds if you are not (you would continue them if you are).

For now, I would recommend that since none of this is easily obtainable for you, you should continue trying on your own for the next six months. If you should become pregnant, the pregnancy will produce the hormones that you require via the corpus luteum cyst that forms from ovulation.

Follow-up Question:

Thank you. I really appreciate your response and think I will go to a walk in clinic next month to at least get a day 21 progesterone test to have some idea of my levels.

I started taking a B50 complex vitamin this month as some women have reported B6 helps with the luteal phase (contains 50 mg of B1, B2, B3, B6, Pantothenic Acid, Choline and Inositol; 50 mcg of B12 and Biotin; and 0.4 mg of Folate.) Would there be any known problems with these vitamins if I were to become pregnant? I am also taking a prenatal vitamin that contains very low amounts of the above noted vitamins (except for Folate which is 1 mg in the pre-natal). Again, thank you very much for your help. It is very much appreciated.

Answer:

Hello Again,

It is okay to continue those vitamins for now, but discontinue them should you become pregnant and stick with the prenatal vitamin only.

Good luck with your treatment!

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
Monterey, California, U.S.A.

More On Luteal Phase Defect

After the January 10th Q & A regarding Luteal Phase Defect while on Clomid, I received another question which I would like to include to further enlighten those who struggle with this problem and are not receiving an adequate explanation or treatment for it..

Question:

Hi Dr. Ramirez, My question is that I have a LP (luteal phase) of 8 days. I ovulate on day 23. I always spot beginning of cycle, mid cycle and after cycle for 2-4 days. I started taking 100mg of B6 vitamins last month and progesterone cream immediately after ovulation. Last month, I began spotting two days post-O (I stopped the cream at that time).

The problem is my spotting has increased (menstruation CD 1-9, spotting CD 10, 11, 15-18, 25-31 and menstruating during new CD 1-10). What can I do about this? I am taking my BBT (temps are elevated post-O, I am also taking OPKs so I know I am ovulating. My Dr has done pelvic u/s (ultrasound), ovarian u/s, etc. everything is normal, so are hormone levels. Is there anything I can do on my own to increase my chances of conception? Or is there anything I can bring to my Dr.'s attention? Help! Thx..

Answer:

Thank you for your question. I would like to explain a little about what the luteal phase is before addressing your concerns. The luteal phase is one of the most exact parts of a woman's cycle, if she is ovulatory. It is the second half of the menstrual cycle after ovulation. The corpus luteum secretes progesterone which prepares the endometrium for the implantation of an embryo. A normal luteal phase is 14 days. However, there is a disorder of the luteal phase whereby this part is short. It is called a luteal phase defect. It sounds like you may have a luteal phase defect, which is cuased by hormonal asynchrony. Hence the abnormal bleeding. The uterine lining (endometrium) is very dependant on appropriate hormonal synchrony to keep it stable. If it is unstable, it breaks apart, hence the bleeding at odd times during the month.

The luteal phase can be supported by using supplemental progesterone. It is generally used beginning on cycle day #16 and extending for two weeks. Of course, a pregnancy test will have to be done because the period may be suppressed. If it is positive, you continue the progesterone until 10 - 12 weeks gestational age.

However, based on your scenario, LPD is not the only problem. You may actually need to go an an ovulation induction protocol with Clomid, Latrezole or Gonadotropins in addition to the progesterone supplementation. These medications will help your ovary to perform normally and synchronize the hormonal situation. It may also alleviate the luteal phase defect.

I hope this helps!

Edward J. Ramirez, MD, FACOG

Executive Medical Director

Fertility and Gynecology Center

Monterey Bay IVF

http://www.montereybayivf.com/

Monterey, CA

Luteal Phase Defect While On Clomid For Timed Intercourse Cycle

Question:


Hi. I am 26 years old and have been trying to conceive for 2 years now. So far my infertility is unexplained. All tests have yielded normal results. My husband's sperm analysis was normal in all categories. Count was 170mil although he did have moderate sperm aggregation (clumping) which I was told should not be an issue since its moderate and there were plenty more sperm doing the right thing. While I do ovulate and have a period on a frequent basis it is not on a 28 day cycle, in fact my cycle lengths range from 26 days to 35 and go up and down from month to month.

I just finished my first round of Clomid. Ultrasound at day 12 indicated one good follicle, my lining was good. At day 21 my progesterone was 22.5. I did ovulate. However, my period was only 1 day in length with a 2nd day of spotting. Normally, I have 2 days of moderate bleeding and then 1-2 days of spotting. Is it normal to have a shorter menses with Clomid?

Also, my cycle was only 27 days. I had a confirmed sugar at day 14. I believe I ovulated on day 16. It has apparently also caused a shorter luteal phase. Is that normal? I was under the impression it would lengthen my cycle. My menses came 6 days after my 21 day progesterone showed 22.5. Is that too sudden of a drop in hormone?

Answer:

Hello. Yes, very often Clomid will shorten a cycle. I am concerned, however, that you had a short luteal phase. This should not be the case, but can happen with Clomid. We call it a "luteal phase defect". If this is the case, it could impair implantation leading to failure or loss of the pregnancy. For this reason, I always add and recommend adding progesterone from day 16. It is an easy thing to do and does not have side effects. The only problem is that it will inhibit a spontaneous period if you don't get pregnant, so a pregnancy test will need to be scheduled.

I also recommend ultrasound surveillance when doing Clomid cycles. Most non-fertility specialists will not do this, as in your cycle. It is the best way to monitor progress and lets you know how many follicles are about to be ovulated. HCG can be given to stimulate ovulation (which also helps with the luteal phase) and helps to time your intercourse best. You should ask your doctor to do this. If he/she looks at you curiously, and without understanding, then you need to find a real fertility specialist. Also, only 4-6 cycles of Clomid are recommended by ASRM and reproductive specialists, after that you need to look at other options.

I hope this answers your question.

Sincerely,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
Monterey, California, U.S.A.