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Clomid does not work well in extremely obese patients (> 200 lbs or BMI > 30).These patients usually have insulin resistance and those patients should be highly encouraged to lose weight before induction of ovulation. Insulin sensitizing agents such as Metformin (Glucophage) should be the primary treatment. Metformin can be started at the dose of 500 mg / day for one week, increased to 500 mg p.o., b.i.d. for the next week, and maintained at 500 mg p.o. t.i.d. from the third week onwards.
Patients should be placed on a BBT chart while on Metformin therapy. Approximately, 35 % of patients will ovulate on Metformin and weight loss only within 2 to 3 months of therapy. For those patients who fail to ovulate on Metformin alone, Clomid can be added at a dosage of 50 mg / day for five days. 80-90% of those patients will ovulate on Metformin and clomiphene therapy.
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