Classification of ovulatory disorders
- Ovarian factor infertility (anovulation) is the primary abnormality in 20% of infertile couples.
- Patients are classified into three groups (Figure 26.1).
- Ovulation induction is one of the most successful means of treating infertility. Thoughtful patient selection is essential.
Methods of ovulation induction
Clomiphene citrate (Clomid, Serophene)
- Indications. The most common medication used to induce ovulation. The treatment of choice for women with chronic anovulation but adequate levels of estrogen and eugonadotropic eugonadism (WHO group 2). Usually not effective for ovulation induction in WHO group 1 women.
- Advantages/disadvantages. Safe, effective, inexpensive, orally administered.
- Mode of action. Clomiphene is a selective estrogen receptor modulator (SERM) structurally related to tamoxifen and diethylstilbestrol (DES). It reduces the negative feedback effect of circulating estrogen, thereby triggering hypothalamic gonadotropin-releasing hormone (GnRH) secretion, and increased release of pituitary gonadotropins (follicle-stimulating hormone [FSH], luteinizing hormone [LH]) leading to follicular recruitment, selection, and ovulation 5–12 days after the last dose.
- Dosage. The initial dose is 50 mg daily for 5 days beginning on day 3 or 5 of the menstrual cycle. The dose is increased in each cycle in 50-mg increments until ovulation is observed. If there is no response to 150 mg daily dosage, further evaluation is warranted.
- Monitoring response to therapy. Follicular development can be monitored ultrasonographically or by urinary LH kits 4–5 days after the last dose of clomiphene. An increased progesterone level 14–17 days after the last clomiphene dose is the hallmark of the luteal phase and implies that ovulation has occurred. At the conclusion of a cycle, either the patient is pregnant or menses occurs, and a further cycle is initiated. Once ovulation has been documented at a given dose of clomiphene, there is no advantage to increasing the dose in subsequent cycles. On average, ovulation usually occurs 5–11 days after the last dose of Clomid.
- Adjunctive therapy.
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