Modes of Ovulation Induction if designed for IUI-Combination of CC & Gonadotrophins,

Causes of Failed Repeated IUI- What should be the combinations of CC & IUI in IUI cycles??

A)In PCO mode of stimulation will be either  CC or FSH:-- max dose of clomiphene :: in the era  of gonadotrophins ,?  Ans:- how much max dose of clomiphene one should  give before switching over to injectable (in  not ART pts )

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 One can go upto 150 mg and find it extremely useful to try this dose before resorting to gonadotropins.  What about Gonadotrophins in IUI for PCO:- If one at all switches over to gonadotrophins  for pcos maximum cost effective dose will be 75 i.u daily and never to exceed that :-Red flag :-warning  more than that will cause ohss.
B) If one is using for unexplained or mild male factor or mild endometriosis: No CC, no letrozole:  use Gonadotrophins only if one is planning for IUI, to promote multi follicular development to improvise IUI results.

Why not gonadotrophins in PCO initially :- As per the expert opinion published in Fert Ster the only indications of using gonadotropin in non-IVF stimulation are
1) hypo hypo type 1 anovulation
2) cc resistant pcos.
3) Premature ovarian failure
4) Hypothyroidism
5) Hyperprolactinemia

CC & Gonadotrophins.-Different schedules.

Schedule 1 :-In this scenario 75 IU daily or 150 on alternate day should suffice adjutant to CC

 Many start  75 u alt days from day 3 ?? 

Schedule 2:-  One can  give cc 100 to max 150mg daily D3 to D7. call her on D8 .if no follicle on either side is nearer to 9mm, then and then only one should Supplemt HMG-150 on alternate day for two doses and depending on response making it daily or reduce frequency in same cycle and  also in next cycle.

 Schedule 3:-If one is in a mind to  add only one dose of Gonadotrophin that may be used  on D9 in CC  cycle.
Schedule 4:-If one is accustomed to supplement hMG with CC then preferable is to add two doses give on D6 and D8
Schedule 5  :-There is another way of supplement  i.e to give daily or alternate day start from D6 or D8

Another interesting way of using gonadotropins

Schedule 7 :-Start gonadotrophins for 5 days D2,3,4,5,6. Add CC  50mg 8hourly from day 6 till trigger. Reason :-This will take care of thin endometrium as well LH surge. Explanations of late initiation of CC :-

Gonadotropin induced folliculogenesis at the beginning of cycle à and resultant estrogen level takes care of adverse effect of cc on endometrium.
At any given starting day of CC in early follicular phase it blocked E-2 receptor at pituitary and hypothalamic level and blocks positive feed back. In latest minimal Stimulation Protocols this action of CC is being exploited to stop the LH surge.

 Many of us don’t use trigger in cc cycle if used for  anovulatory women for ovulation induction. If in such women, the follicle size reaches a mature size before the '5 day wash off period of CC . Would you recommend that HCG is necessarily given in this subset of women?

 With CC one should wait & sincerely try to pull till D14 or 23mm sized follicle whichever comes earlier before giving trigger if no spontaneous ovulation. It will be fair to  start doing urinary Lh after 5 days of last tab of cc daily
For AI( Aromatase Inhibitors):-One should start doing urinary Lh once lead follicle reaches 14 mm.

 Details of Schedule 5:- Gonadotrophin initially and late CC 8 hourly :: plus late CC:-To Start for Gonadotrophin  for 5 days like  D2,3,4,5,6
Add CC 50mg 8hourly from day 6 till trigger Scheduled