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Re: Monitoring ClomidFrom: Rafael Haciski MD (haciski@earthlink.net)Tue Mar 28 23:16:08 2000
The problem is that you can not have a rigid monitoring system as everything depends on response of the patient and monitoring is adjusted appropriately. The monitoring is aimed at documenting the important steps in the process: ...that there are no pre-existing conditions prior to initiating induction (such as ovarian cysts) ...having started induction we want to assure that there is an appripriate and timely response with not excessive number of follicles, hence Cd 12 E2 and sono. We find BBTC much more useful and economical than OPK. ...adequate level of progesterone is important, and not infrequently as the stimulation increases, the length of luteal phase decreases, sometime noting a dramatic and precipitous drop of the progesterone which may have been adequate early in the luteal phase ...good endometrial development must be documented when appropriate level of stimulation is achieved - endometrial biopsy will do that. Usually, we start the pt. on CC 50 on CD 3 and monitor the response with BBTC. Subsequent cycle we increase to CC100 (as the lower dose has been associated with inadequate luteal phase, and other negative effects of CC). If at that level the BBTC looks good (as in ovulation on CD 14) then we focus on decumenting normal luteal phase otherwise, we proceed to the next higer level of CC, 150mg. Additionally, as we reach higher levels of CC, we screen with sono before starting the cycle, and again at ~CD12 to make sure that the stimulated follicles are at some reasonable number. When normal BBTC is achieved, then we document normal luteal phase with: ...normal length on BBTC (12-14 days) ...serum prog. >15 ng/ml on CD 21 ...normal biopsy on CD 26 (in phase by good pathologist) Once "normal" ovulation is documented with above tests, then we give patient 4 cycles on that dose of CC, monitoring only BBTC to assure that each cycle is similar, and a screening sono before initiating CC each cycle. You need to remember to have a logical reason why you obtain a test, that the answer to that test will make a clinical difference in what you do, and that the whole process is more an art than science.
-- Rafael Haciski, MD FACOG Gynecology and Infertility Associates Baltimore, MD 410-825-0020 web......http://www.IVF-MD.com e-mail..GIA@IVF-MD.com
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