Angela’s Story: A Case Study on the Reproductive System

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?