Treating Infertility with Clomid
The most common treatment for infertility is a medicine called Clomid or Clomiphene Citrate. And that's used for women that that aren't making eggs and that aren't ovulating regularly. It, obviously, won't work if the man's sperm is a problem. So, we're assuming now that there isn't a male factor, and that the problem is with the couple, which is that the woman isn't making eggs and isn't ovulating each month.
So, the way the treatment works is that usually we have women that are not ovulating and aren't having regular periods. So, we need to start a period, and we use progesterone for ten days to get a period started. Now, once the period starts it's very important that we're all on the same page about how we're defining cycle days. And so, the very first day of bleeding is considered cycle day 1, and everything is timed after that.
So, what I recommend to my patients is on the first day of bleeding on the calendar to mark “1” and then they fill the rest of that month in “2, 3, 4, 5 6, 7, etc.”, because everything is going to be timed based on that.
So, the Clomid is generally given for five days. It can be started on cycle day 3, but the days 5-9 are the classic approach. If Clomid is given on cycles days 5-9, then you expect ovulation to happen somewhere between days 14-16. And so, after the Clomid is done, a woman wants to have two intercourses about every other day.
It turns out that intercourse every other day is really the ideal frequency for conception. Intercourse more frequently than that can dilute two sperm down, and so each ejaculate has less sperm, intercourse less frequently than that has a chance of missing the ovulation. Generally, we recommend every other day intercourse. But, honestly, you know, if the mood strikes you, and you do it more often, then that's not a problem, if you miss a day. That's not the end of the world. But generally, for about 10 days, from 7 to 10 days, you want to have sex about every other day during the time, when you expect to ovulate.
Then, on cycle day 21 we'll check serum progesterone, which is a blood test, and that will tell us whether you ovulated that month and whether it was a good egg or a not-so-good egg. The higher the number, the higher is the quality of the egg that was ovulating. So, that progesterone gives very important information.
I'll usually have patients to come back after that. We'll go over the cycle to make sure that things were done correctly and check that 21-day progesterone, and do a pregnancy test, and, hopefully, the patient is pregnant at that time.
The usual starting dose for Clomid is 50 milligrams, which is one pill. If a woman fails to ovulate at the 50 milligram dose, then it can be doubled to 100 milligrams, and it can even be tripled to 150. Going beyond 150 milligrams doesn't make a whole lot of sense, because even though it can make ovulation happen, it can make implantation of the egg more difficult in the second half of the cycle. So, we usually don't push the dose much higher than that.
In my personal opinion, if a woman fails with 200 milligrams, then I usually start a second medicine Glucophage or Metformin, which is really a diabetes medicine, but it can help quite a bit in women that don't ovulate with Clomid. But 80% of those will be late if you add the Glucophage. That needs to be a pretty hefty dose about 1,500 milligrams a day, which I usually divided up to 500 milligrams three times a day. You can't start on that dose, because it would give you diarrhea and an upset stomach, so you have to sort of work that dose up. But, once you get up to the dose that we need, we start cycles again with Clomid.