Clomiphen resistance

  Is 100 mg enclomiphene better than commonly prescribed Zu+En combination?  Members prescription preference ??

Enclomiphene resistant/ Clomiphene resistant : How to proceed :      It often happens that a 28 yr old woman , PCOS with normal Hormonal profile and had two courses of ovulation induction done by  100 mg enclomiphene. What is the next practical approach-but in folliculometry there was no ovulation. Next step, according to me will be as follows :members may suggest their own views liberally as this page is “ a sharing of knowledge and wisdom.’-:- Weight loss,& CC+ low dose step up Gonadotrophins protocol works better.

Supplement with  HMG on the last day of CC: Adding CC to GT reduces cost In addition to  addressing  weight management, she can be advised  Traditional CC (Zu+En)  combination as 50 or 100mg  from day 2 or 3 for 5 days. To start GT(Gonadotrophins)  (u-FSH or r-FSH) 50-75 IU on the last day of CC or a day after the last dose of CC, daily and follow her up with alt day folliculometry and watch for response after 3-4 days. If maximum 3-4 lead follicles then such supplemtation of hMG in midfolicular phase is beneficial. Therefore, If failed to ovulate with CC alone next best step will be  CC + Gonadotrophins at low dose with step up is a good option if she has failed to ovulate. If maximum 3-4 lead Follicles seen recruited, gradually step up Gonadotrophin dose, or remain same and reassess, hCG trigger can be given when lead follicle is beyond 18mm.

3)  Chronic low dose step up protocol :--Avoid using CC further after 4 cycles if no ovulation. One can consider  chronic low dose step up protocol in such CC –Gonadotrophin resistant cases ("non-responders") after estimating AMH, AFC and HSG if not doe earlier ,If that too fails to induce ovulation . - In chr. low dose step up, one should  start with daily injection of Gonadotrophin at 37.5 IU only, say up to 7 or even 10 days. Then on day 11 of stimulation document for response and either increment slowly or keep the same. To administer hCG at +18mm..

4) to consider Lap-Hyst with mind set for LOD as well (drilling) . --> followed by IUI + OI. Buy little time and give them enough time as trying time is less.

5) GnRH analogue? Not commonly used.

6)  LOD : But it must be explained to the couple and relative about the drawbacks of LOD about possible decrease of ovarian reserve. Therefore, resort to LOD as a last option. It may utmost decrease the OHSS severity in case of IVF. Chief Indication of LOD:--To document  FSH AND LH on day 2 , if LH >2 times FSH , counsel the  pt for drilling , if pt not willing one  can try with 150 mg cc , may  occasionally have god result specially with added   Metformin .

7) Inositol, once upon a time such  were classified in the B-Complex group of vitamins and still considered a nutritional adjuvant, mostly derived  from plants. Mode of action is not very clear, but helps to control hunger "centre" as well. Many scientists still don’t consider as a "drug" for PCOS, but they consider inositols as any “vitamin-like adjuvant.

8) Vit D is an "in-vogue" drug. No harm giving in moderate dose, though hypervitaminosis is a rare known.

 (9)  May use Use R-FSH instead of HMG in PCOS cases with high LH: - on day 7/day 8: As mentioned earlier to cut cost of r-FSH one can start “clomiphene 100 for 5 days followed by u-FSH from 7 th day onwards. Therefore to prescribe 100 mg cc from day 2 to day 6. Then inj u-FSH 75 IU on day 7, 8, 9.” < but occasionally such low cost policy don’t work. That is why some ART specialists are switching over to r-FSH which is costlier on the plea that  she is pcos, high LH may yield better results. But there is disagreement on this issue,& IUI