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Clinical Case Study
Angela's Story: A Case Study on the Reproductive System

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You are a columnist for a popular website that deals with women's health issues. Visitors to the site can submit their stories and questions through an "Ask the Expert" link on the site. In this scenario, a 26-year-old woman has posted her story and some questions regarding reproductive health.

My name is Angela. I am a 26-year-old married woman with no children. My husband, Doug, and I have been trying to get pregnant for over two years now and my doctor has suggested that I consider fertility drug treatments. The irony of our situation is that I have been taking a birth control pill for five years to prevent getting pregnant, and now my doctor suggests that I take another drug to help me get pregnant.

When I went off birth control, about a year ago, my menstrual cycle became very irregular. I had been taking a birth control drug called Ortho Tri-Cyclen. To be perfectly honest, I don't understand how it works because my periods were more regular when I was on the pill than when I went off of it. My doctor told me that the pill works because it tricks your body into thinking that it is pregnant. That just confused me even more.

When I looked back on my decision to take birth control pills, I realized that I did not really understand how they work. I just do not want to make that mistake again. Before I consider taking any more drugs, I want to understand more about how they work. The drug we’re looking into is called Clomid. I asked my doctor a bunch of questions, but I still feel confused. I looked up some stuff online when I got home. Here is some information that I learned from a website about how Ortho Tri-Cyclen works:

Estrogen and progestin work in combination to suppress the hypothalamic-pituitary-gonadal (HPG) axis. This suppression leads to a decrease in the release of gonadotropin-releasing hormone (GnRH) from the hypothalamus and luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the anterior pituitary. Maturation of the dominant follicle is inhibited under the decreasing levels of FSH and LH. Hormonal contraceptive use also leads to an increase in the viscosity of the cervical mucus, which inhibits sperm penetration and movement through the cervical canal.

I am hoping that you would be able to help me understand how these drugs actually work.

Short Answer Questions

  1. In my research, I found that the levels of "gonadotropins" in the body are critical to understanding how the drugs Clomid and Ortho Tri-Cyclen work. What are gonadotropins? What role do they play in fertility?
  2. Some of the references talk about how "negative feedback" is involved in understanding how these drugs work. Can you explain what is meant by negative feedback?
  3. My doctor told me that birth control pills contain small amounts of estrogen and progesterone, and these hormones prevent me from ovulating. I don’t understand how giving me these hormones in a pill would prevent me from ovulating. I assume that it has something to do with the levels of the gonadotropins that I asked about earlier. Can you explain this to me?
  4. In the information about Ortho Tri-Cyclen, it mentions that the hormones in the pill make cervical mucus thicker and stickier. Does this happen during my natural cycle? How are estrogen and progesterone involved in this process?
  5. My doctor also explained that birth control pills "trick the body into thinking it is pregnant." She explained that women do not normally ovulate when they are pregnant. Can you explain to me why a pregnant woman does not ovulate? How is this related to how the birth control pill works?
  6. My doctor explained that Clomid works by "tricking the brain into thinking that estrogen levels in the body are low." She explained that this is what leads to the extra stimulation of the ovaries to encourage eggs to be released. One of the references for Clomid said this happens because there is less negative feedback. Can you explain to me how this "trick" and the decreased negative feedback are related? Why would these factors lead to the stimulation of the ovaries?
  7. My doctor told me that if I take Clomid, I would be taking it on days five through nine of my normal menstrual cycle. She explained that this is when it will have the greatest chance of stimulating the ovaries. What is going on during this part of the menstrual cycle that makes it the best time to take this drug?
  8. I read an article that mentioned that women on Clomid may be more likely to get pregnant with twins, triplets, or more! The article said that normally there is a dominant follicle that releases a single egg, but Clomid can potentially make lots of follicles release an egg in a given month. How does Clomid do that?

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