The ins and outs of the Clomid Crazies
Three months of my life were spent on the fertility drug Clomid. I’m reluctant to spoil the ending, but given that the narrative in no way builds suspense I will tell you anyway. Reader, it didn’t work.
Getting a prescription of Clomid
Clomiphene Citrate, known affectionately as Clomid by those who have spent time in its company, is a fertility drug often used to help encourage more regular ovulation in those unfortunate souls like me that suffer with dysfunctional ovulation. How I came to be a Clomid user went a little like this. I was prescribed Clomid during my first (and rather horrifying) conversation with my NHS fertility consultant, which for me was a short but highly effective advertisement for functional medicine. My doctor bombarded me with the following information, jammed into the tight 10 minute timeframe and presented like a trailer for a low budget disaster movie:
“From your file it appears that you have PCOS, which will explain why you have been having long and irregular cycles (Excellent, now we are getting somewhere). PCOS is a hormonal condition that is based around insulin resistance (Oh dear, that doesn’t sound good). It is a pre-diabetic condition (Crumpets). The most effective way to manage PCOS is through diet (Yes!). PCOS is associated with infertility due to the irregularity or absence of ovulation (Is there any good news…?). It also hugely increases your chance of miscarriage, still birth, gestational diabetes, and complications at birth (Clearly not). Oh and it is also associated with increased rates of heart disease, diabetes, ovarian and breast cancer (Excuse me whilst I pick my jaw up from off the ground). Soooo... (big reassuring smile from the consultant) the best thing to do, if you are happy, is to pop you on Clomid which will make your body ovulate and hopefully result in pregnancy! Ok then. We’re done here. Good luck (shuffling me out the door).”
Oh, right, yes. That’s the end of the appointment. It wasn’t until the door closed, with me on the other side, that it occurred that I hadn’t asked her about the scary part where she said I was going to die. Heart problems, diabetes, the Big C did she say? This consultant later concluded (wrongly, but be kind, it's a complex and tricky condition) that I did not have PCOS and marked me down as 'unexplained'. So that was how it happened. After the appointment I had a quick weep in the hospital loos, a cuppa in Costa Coffee whilst waiting for my prescription, then travelled home clutching my paper bag of Clomid.
How should Clomid be used?
In the UK Clomid is a hospital prescription only medicine and therefore cannot be obtained over the counter, prescribed by your GP or issued by pharmacies outside of hospital estates. At least this is what I was told by my hospital. I often suspect the NHS of playing fast and loose with the truth, but I have insufficient knowledge to pick out the porkies. I feel like we are engaged in a long running and rather serious game of Cheat.
Clomid is a pill taken orally. What I hadn’t realised is that it comes in 50 milligram pills and your prescription dictates how many pills you take (e.g. 100mg prescription means you’ll take 2 pills and 150mg, 3 pills etc). It is basic arithmetic but still required me to email the hospital to double check that I needed to take 2 pills, not a different pill that is 100mg. I could be (and probably am) a total muppet, so I needed the NHS to be explicit about what they wanted me to do. Nobody wants muppets self-administering hormone altering drugs.
It’s common for people to start on the lowest dose and for the doctor to increase the prescription in following cycles, if required. I’ve heard of one lady being on 250 milligrams, poor lamb. I bet she was sweating like a bitch.
Clomid is usually taken for five days in a row in the beginning of a menstrual cycle. Your doctor will tell you which day to start and it will normally be either day three, four, or five of your cycle, depending on what protocol your doctor is following. The NICE Guidelines for Fertility Problems Assessment and Treatment advise that women who are taking Clomid do not continue treatment for longer than 6 months.
How does Clomid work?
Clomid is often prescribed to women with ovulation dysfunction, such as irregular, infrequent or non-existent ovulation. A prime example is those suffering with polycystic ovary syndrome, or PCOS. Oh, my hand just shot up, who is with me? It is a less common prescription for women with low ovarian reserve or unexplained infertility where the woman ovulates regularly. Apparently, for a woman who has normal spontaneous ovulation, driving the hormonal glands harder with Clomid will not make ovulation any more ‘normal’ and does not increase the chances of pregnancy.
Lucky for me, I do always engage in ‘spontaneous ovulation’, but I used to be an unpredictable ovulatory, with cycles up to 50 days in length. I have never knowingly had a cycle without an egg (since records began in 2015). It may take me a while, sometimes nearly 40 days to ovulate, but an egg always pops out in the end. As to the standard of that egg, I’m making no promises. Given three years and the lack of pregnancy, there is no denying they may be less than prime stock. I strongly suspect that the egg stewing in hormones for weeks longer than normal may be doing the quality no favours.
Clomid works by blocking estrogen receptors in the "hormonal control center" in your brain, making the body think that estrogen levels are lower than they actually are so that you produce more. This in turn causes the body to increase secretion of follicle stimulating hormone (FSH) to help the ovaries to produce follicles, and luteinizing hormone (LH) to encourage ovulation. Clomid helps the body to produce mature eggs in a timely fashion. So does that mean that I spit out immature eggs? Do I? What are immature eggs? All I can think is of my eggs telling each other fart jokes and bouncing off the inner walls of my ovaries whilst giggling hysterically. I want mature eggs, the sort of egg that would fill out self-assessment tax return months before the deadline or offer to be the designated driver on party night. Where are those eggs? Would Clomid whip my eggs into shape and dish out some discipline? Why not give it a go, right.
What does it feel like to be on Clomid? Side effects
Well, here is why you may not want to give it a go. Apparently Clomid turns some people into unbearably moody, short tempered emotional wrecks. I asked my husband Joe whether he thought that I had been unbearable my first month on Clomid (expecting him to say ‘no’, obviously) and he said that I had been a ‘bit weepy, sometimes snappy’ and followed it up with the sincerely meant yet offensive 5 words ‘but no more than usual’. Charming. I unintentionally confirmed his view about my precarious emotional state by doing a theatrical 180 degree turn and flouncing out of the room in a huff.
So what are the side effects of Clomid that we infertiles can expect to endure?
- Mood changes and irritability (known as 'The Clomid Crazies'). Your inner dragon, confined to an internal cage by years of careful social conditioning, may be released and primed to attack your nearest and dearest when least expected. Warn them to take cover.
- Hot flushes. Not like the ones you have when exposed to too much glorious sunshine on a beach holiday or when indulging in glasses of wine in front of a roaring fire, but more of a sweat drops running between your boobs, thrashing the covers off you at night, touch me and I’ll slap you kind of a thing.
- Headaches, visual changes like blurring and double vision, nausea. In me these manifested in a conviction of hypochondriac proportions that I was coming down with the flu. It was definite. No denying it. Until it never fully developed and disappeared immediately at the end of the five days on Clomid.
- Bloating. I have the ability of a camel when it comes to retaining water, so it is hard to tell if I was (even more) bloated. But Clomid is apparently a bloater. It happens when the ovaries respond excessively to the drugs. The ovaries are enlarged and many large follicles are produced which can lead to abdominal pain and swelling. What a treat.
- Breast tenderness. The type of soreness you may usually feel post ovulation. A sore boob is like a beacon to our cat Roger, who takes the opportunity of me lying on the sofa to climb aboard and engage in vigorous kneading of the chest area, until I flick him off in a shriek of pain. Every time. Every single time.
We can all cope with a bit of angry sweating, so let’s get serious, what about the hard core side effects?
- Thin uterine lining. Because of Clomid’s effect on your estrogen levels, it can cause your uterine lining to be thin (a thick lining can help with implantation). This is an issue for achieving pregnancy and thinking ‘thick thoughts’ is not going to fix this, as much as I like to try.
- Drying you up, downstairs. Clomid can also reduce the amount and quality of your cervical mucus. The cervical mucus is designed to be thin and watery, which helps the sperm cells travel up to the fallopian tubes. Clomid can dry up the mucus or change its consistency, interfering with the sperm’s baby making travels.
- The development of cysts of the ovaries. All I’d say to those cysts is ‘good luck finding room in my ovaries’. They are pretty chock a block with cysts as they are. In all seriousness, cysts aren’t good news and you are never going to hear a doctor exclaim with glee ‘Yey! You have a cyst’. No good lies there. However, apparently cysts usually subside spontaneously after treatment. Ah, so no harm done then? Hmm.
- The Big C. So far, there is no conclusive data that Clomid increases cancer risk in women (thank goodness for that). But this is an area where more research is needed as the studies available are contradictory.
- Multiple pregnancies. Because Clomid stimulates the overaries, like a jockey flogging a racehorse, there is a higher chance to popping out more than one egg. About 5-10% of Clomid-induced pregnancies will be twins and below 0.5% will be triplets or more. Multiple pregnancy carries significantly higher risks compared to singleton pregnancy, e.g. miscarriage, premature labour, bleeding problems, high blood pressure, etc. The chances of a natural birth are also slimmer, and I am keen on a natural birth despite my intolerably low pay threshold (described in my HSG blog post). Throughout my first cycle on Clomid my husband and I joked that it would be ‘The Month’ and we were having twins. The chances of me being able to cope financially, physically and logistically with twins was slow slim that surely Sod’s law says it must happen to us? This bubble of hope burst a few weeks later, but it was a delightful delusion to spend the month excitedly muttering to each other, ‘We’re having twins!’.
On the positive side, to date the research has not shown a significant risk for miscarriage, birth defects, or other pregnancy complications from taking Clomid but you should speak with your doctor about any specific concerns.
How is Clomid monitored?
The NICE Guidelines for Fertility Problems Assessment and Treatment advise that ultrasound monitoring should be offered during at least the first cycle of Clomid to ensure that the dose minimises the risk of multiple pregnancy. During the treatment cycle, vaginal ultrasound scanning using a twat wand is required to monitor the response of the ovaries to Clomid. This is called “follicular tracking”, which sounds like an entertaining video game. Maybe there should be an infertility video game, where the player has to correctly diagnose the patient and treat them quicker than the NHS. I should be cautious sharing such excellent business ideas for fear they will be snapped up, so back to Clomid. There is also concern that Clomid may increase the risk of cysts developing in the ovaries, which can also be monitored by ultrasound. My hospital didn’t follow NICE guidelines and when I asked whether ultrasounds would be available the answer was ‘nah’. There were insufficient resources available to comply with the NICE guidance. So just be warned that you may always have the optimal level of monitoring.
Instead my cycles were ‘monitored’ (in the loosest sense of the word due to late results and lost tests that are too tedious for inclusion here) via progesterone blood tests taken during the middle of the luteal phase, i.e. approximately 7 days after ovulation. The results of the progesterone test show whether you have ovulated during that cycle and therefore whether the Clomid is working and the dose correct. Doctors may use these results to alter your dose for the following cycles. Progesterone tests will not show whether you are developing cysts or at risk of a multiple pregnancy. If you attend the same hospital as me, you just have to guess about those.
How successful is Clomid?
Every monthly attempt to conceive with Clomid results in a 15-20% pregnancy rate per attempt. For women above the age of 35, the success rate of Clomid drops to about 6%-8% per cycle as a direct result of ageing. Damn you, ageing. Why do you always have to be a dark cloud hanging over our fertility? Overall, for all cycles combined, between 75-80% of women taking Clomid will successfully ovulate, but fewer than 50% of patients will conceive.
That means that for 20-25% of women, Clomid will have absolutely no impact whatsoever. Their ovulation won't budge. I fell into that camp. Despite extremely high expectations the only bump I received was my fall back to reality. Through food and lifestyle changes I had regulated my cycles prior to taking Clomid, but to demonstrate how little impact Clomid had on me, can you guess from the three charts below which one was a Clomid cycle?
Ovulation: day 16
Cycle length: 28 days
Ovulation: day 18
Cycle length: 29 days
Ovulation: day 18
Cycle length: 29 days
The correct answer is October 2016, and only October. The two either side were natural cycles. The only real difference in the cycles are the frequency of optimistic red hearts (bless us, we really tried).
Am I glad I tried Clomid?
Absolutely. For me, the mild side effects, especially for a short 3 month stint, were worth it for the chance that Clomid may bring us a baby. It does have a happy ending (not the rude sort) for many couples. For everyone out there about to embark on Clomid, or currently sweating their way through a Clomid cycle, I wish you all the luck in the world. You've got this.