|CLOMIPHENE / LETROZOLE PROTOCOL|
Both clomiphene citrate and letrozole are prescribed for five days each cycle. Initial dose is usually one tablet each day of the specified days. However, the dosage may be increased or decreased by your physician based on your individual situation. The number of tablets may be increased to as much as four daily, if the lesser dosage does not result in ovulation, but rarely are more than two tablets required.
If either you or your physician suspect you might be pregnant, do not take clomiphene/letrozole as there may be a possibility of increased risk of congenital defects. IF YOU THINK YOU MAY BE PREGNANT, DO NOT TAKE CLOMIPHENE OR LETROZOLE. NOTIFY YOUR PHYSICIAN!
First treatment cycle
- Beginning on cycle day 3, start clomiphene citrate 50 mg (or letrozole 2.5 mg), one by mouth each day through cycle day 7.
- On cycle 9 or 10, schedule appointment for lab work (LH and FSH). If the LH level is two to three times higher than the FSH level, clomiphene citrate/letrozole is less likely to work for you.
- On cycle 12, you will begin daily testing of urine to detect an LH surge, the signal that ovulation will occur in 24-36 hours. Ovulation predictor kits (LH predictor) may be purchased here at GRS or at most any pharmacy. The LH urine test is best performed with the second urination of the day. (usually between 7 a.m. and 10 a.m.) If a surge has not occurred by cycle day 16, call the office to schedule an ultrasound. This is to check for follicular development and measure the thickness of the uterine lining.
- When you have a surge, you should have intercourse that evening and for the next two nights. (Note: Surge is any color change that is close to the "control". May be lighter with clomiphene or letrozole.)
- If you had a surge and had intercourse as suggested above and it is now day 35 and a period has not started, do a pregnancy test.
- If pregnancy test is positive, please call the office. You will be asked to come in for blood work (a specific kind of pregnancy test, a quantitative hCG). You will then be asked to return in two days to have this specific pregnancy test repeated. This test is repeated so that we can measure the amount of hCG (human chorionic gonadotropin, which is produced after pregnancy occurs), looking for at least a 60% increase in the level. This helps us to know whether this is a pregnancy that is progressing appropriately.
- If it appears the pregnancy is progressing appropriately, you would then be scheduled for your first OB ultrasound approximately 2 weeks later.
- If pregnancy test is negative and another cycle of clomiphene citrate/letrozole is to be started, you would follow the directions below.
Second and Subsequent Clomiphene Citrate or Letrozole Cycles
- At the onset of menstrual flow, before day three, you need to be scheduled for a "clomiphene/letrozole check". A clomiphene/letrozole check will now be required each month prior to prescribing the medication. This allows us to review your previous treatment cycle. A pelvic exam or ultrasound ensures that the clomiphene or letrozole has not stimulated the development of an enlarged ovarian cyst. If your period begins on a Friday, contact us immediately to arrange for an appointment. (You may be asked to postpone the baseline evaluation until cycle day three if day three falls on a Sunday.) If your exam is normal and the clomiphene/letrozole is working properly, it will again be prescribed to be started on day three of your cycle.
- Then, repeat instructions above (under "First Treatment Cycle") or as instructed by your physician.
More than half the clomiphene/letrozole pregnancies occur during the first three cycles and more than 3/4 occur at the 50mg. (or 2.5 mg letrozole) dose. Rarely will pregnancy occur when more than 100mg/day (two tablets) are necessary. If you have not conceived after three cycles, intrauterine insemination will be recommended to improve your chances of conceiving. If you have not conceived after four to six cycles, either combined clomiphene (or letrozole)/hmg/insemination or Gonal-F/Follistim injections and intrauterine insemination will be recommended.
(brand names Serophene, Clomid)
(brand name Femara)
Both clomiphene citrate and letrozole are medications used to treat infertile women who have an ovulation problem. These medications work by helping your pituitary gland (located at the base of the brain) improve the stimulation of developing follicles (eggs) in the ovaries. Neither clomiphene citrate nor letrozole may help a woman become more fertile if she is already ovulating normally. For that reason, these medications are most often prescribed to those patients who have been found to have an abnormality with their cycle.
Clomiphene is often referred to as the "fertility pill". Letrozole is very similar to clomiphene in the way it works. However, letrozole is quickly cleared from the body. It only works for the cycle in which it is taken and is less likely to adversely affect the uterine lining and cervical mucous. With clomiphene, one may experience effects 6-8 weeks after stopping the medication. Both medications are prescribed for five days each cycle, usually beginning on day three and continuing through day seven. The usual initial dose for clomiphene is 50 mg, one tablet daily. The number of tablets can be increased to as many as four daily, if a lesser dosage does not result in ovulation. Rarely are more than two tablets required. Clomiphene should be repeated each cycle until pregnancy occurs, or your doctor discontinues it. The usual dosage of letrozole is 2.5 mg., one tablet each day.
Of all women treated with clomiphene, or letrozole, 60% to 80% will ovulate normally. However, only half of those patients who ovulate will become pregnant. It is not known why only half of the women who apparently ovulate with clomiphene or letrozole therapy become pregnant. It is suspected that factors other than inadequate ovulation may be contributing to the fertility problem. Therefore, if you are not pregnant after three or four cycles, additional testing such as hysterosalpingogram or laparoscopy may be necessary. If you have polycystic ovary syndrome, a trial of metformin (Glucophage) therapy may be advised.
Some 10% to 20% of women taking clomiphene or letrozole will experience side effects. By far, most of these are minor and temporary in nature. They include such things as hot flashes, blurred vision, nausea, bloating sensation, and headache. Serious side effects are rarely seen with either medication. There are two side effects associated with clomiphene or letrozole therapy that warrant specific discussion. The first is the possibility of multiple pregnancy. The frequency of twins occurring in women who conceive while taking clomiphene or letrozole has been reported to be as high as 10%. Triplets may occur as frequently as 1 in 400 births, and quadruplets in 1 in 800 births. Neither clomiphene nor letrozole is the "fertility drug" you may have heard in the news bulletins often associated with large numbers of infants, such as quintuplets. Newer studies suggest that long-term use of either clomiphene or letrozole for more than 12 cycles may place you at an increased risk of developing ovarian cancer. Secondly, clomiphene and letrozole have also been associated with the occasional development of ovarian cysts. These cysts are not true growths of the ovary and within a few weeks will resolve without treatment. However, on an extremely rare occasion, these cysts have been known to cause internal bleeding or twist, requiring surgery and removal of the involved ovary. However, I must again emphasize that such a complication is extremely rare.
Clomiphene or letrozole stimulated cycles are not unlike normal cycles in that there is only a 20-25% chance of conception occurring each cycle during the first three to four treatment cycles, even if the medication is working properly. (Results may be lower with unexplained infertility.) This means that at least four to six cycles of treatment are necessary before one has given either medication an adequate trial. Recent studies indicate that if a pregnancy occurs as a result of the clomiphene/letrozole treatment, there is no clinically significant increased risk of miscarriage or congenital birth defects when compared to other infertile couples who conceived without clomiphene/letrozole treatment. However, women with polycystic ovary syndrome may be at higher risk for miscarriage during a pregnancy conceived using either of these medications.