Both clomiphene citrate and letrozole are prescribed for five days each cycle. Initial dose is usually one tablet each day of the specified days. However, the dosage may be increased or decreased by your physician based on your individual situation. The number of tablets may be increased to as much as four daily, if the lesser dosage does not result in ovulation, but rarely are more than two tablets required.

If either you or your physician suspect you might be pregnant, do not take clomiphene/letrozole as there may be a possibility of increased risk of congenital defects. IF YOU THINK YOU MAY BE PREGNANT, DO NOT TAKE CLOMIPHENE OR LETROZOLE. NOTIFY YOUR PHYSICIAN!

First treatment cycle

1. Beginning on cycle day 3, start clomiphene citrate 50 mg (or letrozole 2.5 mg), one by mouth each day through cycle day 7.
2. On cycle 9 or 10, schedule appointment for lab work (LH and FSH). If the LH level is two to three times higher than the FSH level, clomiphene citrate/letrozole is less likely to work for you.
3. On cycle 12, you will begin daily testing of urine to detect an LH surge, the signal that ovulation will occur in 24-36 hours. Ovulation predictor kits (LH predictor) may be purchased here at GRS or at most any pharmacy. The LH urine test is best performed with the second urination of the day. (usually between 7 a.m. and 10 a.m.) If a surge has not occurred by cycle day 16, call the office to schedule an ultrasound. This is to check for follicular development and measure the thickness of the uterine lining.
4. When you have a surge, you should have intercourse that evening and for the next two nights. (Note: Surge is any color change that is close to the "control". May be lighter with clomiphene or letrozole.)
5. If you had a surge and had intercourse as suggested above and it is now day 35 and a period has not started, do a pregnancy test.
6. If pregnancy test is positive, please call the office. You will be asked to come in for blood work (a specific kind of pregnancy test, a quantitative hCG). You will then be asked to return in two days to have this specific pregnancy test repeated. This test is repeated so that we can measure the amount of hCG (human chorionic gonadotropin, which is produced after pregnancy occurs), looking for at least a 60% increase in the level. This helps us to know whether this is a pregnancy that is progressing appropriately.
7. If it appears the pregnancy is progressing appropriately, you would then be scheduled for your first OB ultrasound approximately 2 weeks later.
8. If pregnancy test is negative and another cycle of clomiphene citrate/letrozole is to be started, you would follow the directions below.

Second and Subsequent Clomiphene Citrate or Letrozole Cycles

1. At the onset of menstrual flow, before day three, you need to be scheduled for a "clomiphene/letrozole check". A clomiphene/letrozole check will now be required each month prior to prescribing the medication. This allows us to review your previous treatment cycle. A pelvic exam or ultrasound ensures that the clomiphene or letrozole has not stimulated the development of an enlarged ovarian cyst. If your period begins on a Friday, contact us immediately to arrange for an appointment. (You may be asked to postpone the baseline evaluation until cycle day three if day three falls on a Sunday.) If your exam is normal and the clomiphene/letrozole is working properly, it will again be prescribed to be started on day three of your cycle.
2. Then, repeat instructions above (under "First Treatment Cycle") or as instructed by your physician.

More than half the clomiphene/letrozole pregnancies occur during the first three cycles and more than 3/4 occur at the 50mg. (or 2.5 mg letrozole) dose. Rarely will pregnancy occur when more than 100mg/day (two tablets) are necessary. If you have not conceived after three cycles, intrauterine insemination will be recommended to improve your chances of conceiving. If you have not conceived after four to six cycles, either combined clomiphene (or letrozole)/hmg/insemination or Gonal-F/Follistim injections and intrauterine insemination will be recommended.