PATIENT CONSENT FOR THE USE OF
CLOMIPHENE CITRATE (CLOMID OR SEROPHENE)
Clomiphene Citrate is an orally administered medication to induce (bring on) ovulation in women who have
ovulatory disorders.
Approximately 10% of patients taking Clomiphene will experience some side effects or adverse reactions.
Common side effects you may have include:
- Multiple births occur in 6-10% of women who conceive on Clon-dphene. The vast majority of deliveries
are twins, with less than 1% of reported deliveries being triplets or more. If a multiple pregnancy occurs,
complications of the pregnancy include an increased risk of premature labor and/or delivery, fetal injury
and/or death due to prematurity, miscarriage and toxemia of pregnancy.
- Miscarriage rates in women taking Clomiphene vary from 10-25%. The miscarriage rate of the general
population is 10-20%. The reason for a possible increased miscarriage is unknown.
- Ovarian hyperstimulation may occur causing the formation of benign ovarian cysts. These cysts may
cause abdominal pain, discomfort, swelling, and possibly can lead to twisting of the ovary or rupture
which may require abdominal surgery. The cysts usually regress over a period of two to four weeks, but
may persist longer. Promptly call your physician if you experience pain or an increase in discomfort.
- Breast soreness and/or tenderness.
- Hot flashes may occur during the time of taking Clomiphene and are self-limited with no consequences.
- Transient hair loss may be noted, especially if repeated courses of clomiphene are required. This is a
self-limited process which stops once treatment is discontinued and is not permanent.
- Visual blurring may occur with clomiphene. This is a self-limiting process, but requires that you report
the reaction promptly to your physician. Avoid driving, operating machinery or any activity requiring
visual skills until the blurring has completely resolved.
- The risk of congenital malformations (birth defects) in children conceived by clomiphene is no different
from the incidence of congenital malformations in the general population. However, one cannot exclude
the possibility of an abnormal baby in patients taking clomiphene. Clomiphene should never be taken if
a patient suspects that she may be pregnant or once pregnancy is confirmed.
- There is a potential, but as yet unproven, increase in ovarian cancer risk with women taking fertility
drugs. These medicines include clomiphene citrate (clomid, serophene), Bromocreptine (Parlodel) and
HMG (pergonal, metrodin).
- Other minor reactions include: headache, nausea, vomiting, fatigue, insomnia, dizziness, and
nervousness. These are limited to the cycle of treatment with clomiphene.
If you experience these or other adverse reactions, or have any questions concerning your treatment with
clomiphene, please contact the office at (408) 356-0431.
I have read the above information and have had all questions answered to my satisfaction. I consent to the use
of clomiphene citrate.
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Date
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Patient's Name
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Patient's Signature
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Clomid Consent as pdf file |
