Although there are many possible additional diagnostic and interventional techniques, protocols for<unk>  generally consist of: *Determining the first day of the last menstruation, which is termed day 1. In case of amenorrhea, a period can be induced by intake of an oral progestin for 10 days. *Daily administration of the<unk>  regimen, starting on day 3, 4, or 5, and it is usually taken for 5 days. *Sexual intercourse or artificial insemination by the time of<unk> . Ultrasonography Pregnancy rates in<unk>  when using antiestrogens, as functions of the size of the leading follicle as measured by transvaginal ultrasonography at days 11 - 13 (bottom scale), as well as the thickness of the endometrial lining (4 different curves). During<unk> , it is recommended to start at a low dose and monitor the ovarian response with transvaginal ultrasound, including discernment of the number of developing follicles. Initial exam is most commonly started 4–6 days after last pill. Serial transvaginal ultrasound can reveal the size and number of developing follicles. It can also provide presumptive evidence of<unk>  such as sudden collapse of the preovulatory follicle, and an increase in fluid volume in the rectouterine pouch. After<unk> , it may reveal signs of luteinization such as loss of clearly defined follicular margins and appearance of internal echoes. Supernumerary follicles A cycle with supernumerary follicles is usually defined as one where there are more than two follicles >16 mm in diameter. It is generally recommended to have such cycles cancelled because of the risk of multiple pregnancy (see also the "Risks and side effects" section below). In cancelled cycles, the woman or couple should be warned of the risks in case of supernumerary follicles, and should avoid sexual intercourse or use contraception until the next menstruation.<unk>  of final maturation (such as done with hCG) may need to be withheld because of increased risk of ovarian hyperstimulation syndrome. The starting dose of the inducing drug should be reduced in the next cycle. Alternatives to cancelling a cycle are mainly: *Aspiration of supernumerary follicles until one or two remain. *Converting the protocol to IVF treatment with embryo transfer of up to two embryos only. *Selective fetal reduction. This alternative confers a high risk of complications. *Proceeding with any multiple pregnancy without fetal reduction, with the ensuing risk of complications. This alternative is not recommended. Lab tests The following laboratory tests may be used to monitor induced cycles: *Serum estradiol levels, starting 4–6 days after last pill *Post-coital test 1–3 days before<unk>  to check whether there are at least 5 progressive sperm per HPF *Adequacy of luteinizing hormone surge LH surge by urine tests 3 to 4 days after last clomifene pill *Mid-luteal progesterone, with at least 10 ng/ml 7–9 days after<unk>  being regarded as adequate. Final maturation<unk>  Final maturation<unk>  and release, such as by human chorionic gonadotropin (HCG or hCG) or recombinant luteinizing hormone, results in a predictable time of<unk> , with the interval from drug administration to<unk>  depending on the type of drug. This avails for sexual intercourse or intrauterine insemination to conveniently be scheduled at<unk> , the most likely time to achieve pregnancy. As evidenced by clomifene-induced cycles, however, triggering oocyte release has been shown to decrease pregnancy chances compared to frequent monitoring with LH surge tests. Therefore, in such cases, triggering oocyte release is best reserved for women who require intrauterine insemination and in whom luteinizing hormone monitoring proves difficult or unreliable. It may also be used when luteinizing hormone monitoring has no shown an luteinizing hormone surge by cycle day 18 (where cycle day 1 is the first day of the preceding menstruation) and there is an ovarian follicle of over 20 mm in size. Repeat cycles<unk>  can be repeated every menstrual cycle. For clomifene, the dosage may be increased by 50-mg increments in subsequent cycles until<unk>  is achieved. However, at a dosage of 200 mg, further increments are unlikely to increase pregnancy chances. It is not recommended by the manufacturer of clomifene to use it for more than 6 consecutive cycles. In women with anovulation, 7 - 12 attempted cycles of pituitary feedback regimens (as evidenced by clomifene citrate) are recommended before switching to gonadotrophins, since the latter ones are more expensive and less easy to control. It is no longer recommended to perform an ultrasound examination to exclude any significant residual ovarian enlargement before each new treatment cycle.
Ovulation induction
Androgen suppression
Immunocontraception
Osteostimulation
Hepatoprotection
Ovarian stimulation
Uterine contraction
Superfecundation