In such cases, studies have observed a clinical pregnancy rate 5.6% per cycle with clomifene treatment vs. 1.3%–4.2% per cycle without treatment.Proper timing of the drug is important; it should be taken starting on about the fifth day of the cycle, and there should be frequent intercourse.The following procedures may be used to monitor induced cycles:
Follicular monitoring with vaginal ultrasound, starting 4–6 days after the last pill. Serial transvaginal ultrasound can reveal the size and number of developing follicles. It can also provide presumptive evidence of ovulation such as the sudden collapse of the preovulatory follicle, and an increase in fluid volume in the rectouterine pouch. After ovulation, it may reveal signs of luteinization such as loss of clearly defined follicular margins and appearance of internal echoes. Serum estradiol levels, starting 4–6 days after the last pill
Adequacy of LH surge by urine LH surge tests 3 to 4 days after last clomifene pill
Post-coital test 1–3 days before ovulation to check whether there are at least 5 progressive sperm per HPF
Mid-luteal progesterone, with at least 10  ng/ml 7–9 days after ovulation being regarded as adequate.Repeat dosing: This 5-day treatment course can be repeated every 30 days. The dosage may be increased by 50-mg increments in subsequent cycles until ovulation is achieved. It is not recommended by the manufacturer to use clomifene for more than 6 cycles.It is no longer recommended to perform an ultrasound examination to exclude any significant residual ovarian enlargement before each new treatment cycle.
Ehrlichiosis ewingii infection is an infectious disease caused by an intracellular bacteria, Ehrlichia ewingii. The infection is transmitted to humans by the tick, Amblyomma americanum. This tick can also transmit Ehrlichia chaffeensis, the bacteria that causes human monocytic ehrlichiosis (HME). Symptoms and signs
Patients can present with fever, headache, myalgias, and malaise. Laboratory tests may reveal thrombocytopenia, leukopenia, and evidence of liver damage. Mechanism
Humans contract the disease after a bite by an infected tick of the species Amblyomma americanum. Those with an underlying immunodeficiency (such as HIV) appear to be at greater risk of contracting the disease. Compared to HME, ewingii ehrlichiosis has a decreased incidence of complications.Like Anaplasma phagocytophilum, the causative agent of human granulocytic ehrlichiosis, Ehrlichia ewingii infects neutrophils. Infection with E. ewingii may delay neutrophil apoptosis. Diagnosis
In endemic areas, a high index of suspicion is warranted, especially with a known exposure to ticks. The diagnosis can be confirmed by using PCR. A peripheral blood smear can also be examined for intracytoplasmic inclusions called morulae. Treatment
The treatment of choice is doxycycline. See also
Human monocytic ehrlichiosis
Human granulocytic ehrlichiosis
Ehrlichiosis (canine)

References


== External links ==