Q.1:- When given choice will you prescribe clomiphene or
only active agent as Enclomiphene ? I
understand that many a clinician are biased for those drugs to which she/ he is
comfortable or familiar for years together . By contrast there is another group
of energetic ,possibly more academic clinicians who accept
any new drug too quickly before robust data are available,
Who is your friend - Enclomiphene and Zuclomiphene ?? Ans:-Enclomiphene and Zuclomiphene which e is
best ?? Few pharma
company have come up with Enclomiphene Only —
Q.2:-Enclomiphene Only —why?? Logic:-Clomiphene citrate is a racemic
mixture of stereoisomers, Enclomiphene and Zuclomiphene in the ratio of 62% :
38%.
We have to
remember that enclomiphene is
the one primarily responsible for ovulation induction, while zuclomiphene
is the one primarily responsible for negative effects.
This basic informations on pharmaco chemistry prompted
many gynaecologists to prescribe the
active pure isomer of clomiphene citrate viz. Enclomiphene
for ovulation induction
Q.3: What
are the negative effects with clomiphene
citrate if combined form is used?? Ans:- The negative effects commonly
encountered are 1) endometrial thinning
in 15-50% of patients, 2) poor cervical mucus and 3) CC resistance in 15-40% of cases.
Q.
4:--,1:-What is Clomiphene resistance Ans: No ovulation inspite of higher dose of
CC. By contras CC Failure implies:--Ovulation
but no pregnancy=(the presumable causes of contd infertility inspite of
documented ovulation lliculomeytry) & serum progesterone on day 21-22 is
reassuring still no pregancy may be frusta .
Q.
5:-- Causes of CC
failure? Why do women fail conceive
despite ovulation??
The known
causes of failure to conceive I CC cycle despite documented ovulation are 1)Thin endometrium 2) short implantation
window in CC cycles 3) Poor oocyte
quality due to persistent high androgens inside the Liquor Folliculi in PCO cases 6) Less favourvbale growth
factors in granulosa cells I CC cycles and sanity receptor induction in Endometrium.
Q. 6: -CC is ne part but followings are also
important like a)
Correction of Stress/ daily brisk walking & Exercise/ Eating healthy diets
and avoiding street foods and oily foods, Correction of
elevated PRL,TSH, and insulin by metformin or myoinositol.
Q. 7 : What will be the treatement of C
Resistance. The options are
1) May be letrozole only or with adjuncts like Myo inositol 2-4 Gm Oc or
Metformin 2000mg in divided doses or 2) Letrozole flowed by
gonadotrophins from cycle day 8 to day 12 as needed inj hMG(cheap urinary will
achieve identical success) may be tried
if age < 27yrs and trying time is < 4 yrs, 3) Drilling. if LH>12 on
day 3of spont cycles & large volumes of ovaries like > 12 ml
Q. 8:-” If she does
not agree for LOD or there are indefinite/ suboptimal indications of LOD and to add to the problem the alternative
agent or protocol of ovulation induction is Chr low dose protocol. then proceed
for Low dose step up R-FSH 50 units
till follicular recruitment is visible then maintain that dose & increase
if no recruitment.
Q. 9:-Is there any role of CC in Male Subfertility.
Testicular causes:- Male hypogonadism is one of
the major reasons of male infertility. About 30 % male factor subfertility
suffer from hypogonadism due primarily to testicular cause (low testosterone,
high FSH& LH, low inhibin-B)
.This is often characterized by deficiency in testosterone hormone production while in case of secondary hypogonadism, defect lies at the level of
hypothalamic-pituitary axis(Low FSH, low LH, high inhibin).
How Clomiphene acts in male subfertility where Leydig cells fails to
synthesize adequate Testosterone? Ans; we know that a very large amount testosterone
must be synthesized by Leydig cells which will diffuse to supporting cells called Sertoli
cells which will pass the freshly locally produced Testosterone to primary spermatocytes and facilitate mitois of
primary spermatocytesà followed by meiotic
division . If Testosterone concentration synthesized by Leydig cells is suboptimal then there will be poor
division of pri spermatocytes. I this
context remember that in case of oocytes mitotic Divion never occurs after
birth but in males mitotic division of gametes
continues to occur .
Treating male hypogonadism by accelerating the endogenous production of testosterone instead
of exogenous hormonal preparation is the ideal choice. Thus, the ideal
treatment is by blockade of E2 synthesis, secretion of more FSH and LH and up
regulation of the testosterone secretion by testes
Investigations in a case
of anovulation.
The following women are
contraindications for CC:
1) WHO Type 1:-Low levels
of FSH & E2,
2) Women who fail to
respond to withdrawal bleeds are not the candidates for CC.
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