Clomid

Clomid (or clomiphene citrate) is one of the main fertility medications used in this country.  It is a pill, and it is usually given for 5 days near the beginning of the cycle.  It's simple to take and inexpensive.  Check with your local pharmacy, but it now one of Target, Sam's Club, and Walmart's $9 prescriptions.  Clomid has been around since the 1960's, and so we have a lot of experience with it.

Clomid works by blocking estrogen receptors.  The pituitary monitors estrogen levels to figure out what the ovaries are doing.  When the receptors are blocked, the pituitary can't see the estrogen being made by the ovaries.  This makes the pituitary think that the ovaries are not working, and it will send out more hormones (FSH and LH) in an effort to get the ovaries working again.  This extra FSH and LH can get a woman who is not ovulating to ovulate.  It is also used to "superovulate" woman who are already ovulating.  The goal with superovulation with Clomid is to get two, sometimes three, eggs ovulating rather than just one.  More eggs means more chance of getting pregnant.  It also means more chance of ending up with more than one baby too.  Clomid has an 8-10% risk of creating twins, and a rare chance of triplets or more occurring.

Clomid does have some side effects.  The most common side effect is hot flashes.  These are just like the hot flashes women in menopause get, and they are a result of blocking the estrogen receptors.  A hot flash is an episode where a woman feels very, very hot for a few seconds and then returns to normal.  She may turn a little red too and may even feel sweaty.  These are not dangerous, but they can be annoying.  Because there is a possibility of multiple eggs ovulating, one can feel pelvic discomfort too.  This is usually an ache or crampy feeling very low in the pelvis .  It can feel worse with sudden jarring movements too.  Many women say it feels like menstrual cramps.  Moodiness can also occur.  This is similar to the feeling of PMS, with a "quick to tears, quick to anger" feeling.  There are two side effects to watch out for: headaches and visual changes.  If you seem to be having a lot more headaches than usual or you notice changes in your vision, call you doctor.  These will go away when you stop the medication, but we don't want you to be in pain or drive around with impaired vision.  Your doctor can switch the medication to another type, so you will still be able to try to get pregnant.

Clomid is often combined with intrauterine inseminations, which is a procedure where sperm is put  into the uterus on the day of ovuation (see the previous blog entry on male factor infertility for a more in depth description).  This is because Clomid can thicken the mucus in the cervix and make it harder for the sperm to get through the cervix and into the uterus.  An injection of hCG is often used to time the IUI.  hCG will cause ovulation to occur approximately 36 hours later, and this is handy for scheduling the IUI.  The combination of Clomid and IUI has a 10% chance of success each cycle.  This may seem low, but consider that a couple who has already been trying for a year to conceive has about a 3% chance of conceiving by continuing to try on their own and a fertile couple has about a 20% chance each time they try.  Usually Clomid is given for 3 to 6 cycles before other options are recommended.  There is a question as to whether long term use (greater than a year) may raise the risk of ovarian cancer.  Although most studies do not show an increased risk, it is still better to be safe and limit Clomid's use to 3 to 6 months.

There are other medications that work similarly to Clomid and can be used when Clomid is causing side effects like headaches or visual changes.  The most commonly used are Femara and tamoxifen.  Neither of these are FDA approved for fertility treatment, as their main use, and FDA approval, is for the prevention of breast cancer.  There is quite a bit of data, however, on their use in fertility.  They appear to be safe and effective.  They have similar side effects to Clomid, but usually don't cause the headaches or visual changes.

In summary, Clomid is an easy to administer, mild fertility medication that is often the first-line treatment choice for ovulation problems, a single blocked fallopian tube, unexplained infertility, or women whose partners have sperm issues (see previous blog entries about tubal disease and sperm problems).  It will induce ovulation and can oftentimes get 2-3 eggs ovulating.