Dear Professor Winston

I am interested in your thoughts on the use of clomifene in a case of unexplained infertility (secondary). I have had two pregnancies previously, one of which was unsuccessful as it was partially molar and the second, happily, led to the birth of my son in 2009 (by emergency section). In both these cases, I became pregnant very quickly within 2 months of trying. I am now 38, nearly 39 and have been trying to conceive for two years. Following investigations, my husband’s sperm count has been confirmed as healthy and I have just recently had a laparoscopy to check for tubal blockages or adhesions. The latter revealed no adhesions, but the results of the tubal dye test were less clearcut indicating that one tube was clear and one uncertain – the surgeon suspected a spasm rather than confirmed a blockage. The options I’ve been given now are to try clomifene or proceed to self funded IVF. A previous day 21 progesterone test indicated that I have ovulated in the past 6 months. I was using ovulation sticks for a while previously but didnt always get a positive result each month. I have found your responses to other posters very helpful and would be grateful of your thoughts on the clomifene option. Many thanks, C

Reply….

Dear C

An important question – thank you. If you are ovulating, which certainly seems to be the case, I don’t think Clomiphene (or Clomifene as it is sometimes spelt) is a good idea at all. And if you were to take Clomiphene then taking it in an ad hoc way like this – without monitoring – is not a good idea either. In my view an ultrasound would be needed to ensure you really are producing follicles as a result of the stimulation. BUT – if you are already ovulating, Clomiphene may actually interfere with the normal process. It is worth remembering that Clomiphene was originally devised as a method to produce contraception by halting ovulation or interfering with the lining of the uterus. It was only when they found that it increased fertility in some experimental rats did somebody realise that it might be used to stimulate ovulation in women who were not producing eggs. I am amazed how often Clomiphene is prescribed to women who are ovulating already and I know of no good data which shows this improves your chance of getting pregnant. And in older women, say over the age of around 38, it may decrease fertility. In my view, you cannot beat regular pleasurable intercourse without drugs – and dare I say it, without timing either. These ovulation test kits – widely marketed – are a dubious benefit for most women and detract from making spontaneous love. Indeed, it could be that careful monitoring may even decrease the chance of some women, particularly in later age, conceiving. The fact that you are not getting a positive stick test for ovulation each month may possibly be age related and that the timing of your LH surge is not properly synchronised. This is quite common in women who are a bit older but doesn’t mean you can’t conceive.

Now – to come back to the results of the tubal dye test. Amongst the commonest causes of secondary infertility are tubal damage, or damage inside the uterine cavity. If this has not been done already, I cannot stress how valuable an old-fashioned X-ray of the tubes and uterus is. It is hugely better than hysteroscopy (a telescope inspection of the uterus, and easily beats pushing dye through the tubes using an ultrasound monitor). Added to which, it is one of the cheapest of all infertility tests.

I hope this is helpful,
Best wishes

Robert Winston

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