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Ovulatory problems account for 20 to 30% of infertility cases.

1 April 2009

Ovulatory dysfunction is abnormal, irregular, or absent ovulation. Menses are often irregular or absent. Diagnosis is often possible by history or can be confirmed by measurement of hormone levels or serial pelvic ultrasonography. Treatment is usually induction of ovulation with clomiphene or other drugs.

Symptoms and Signs

Ovulatory dysfunction is suspected if menses are absent, irregular, or not preceded by symptoms, such as breast tenderness, lower abdominal bloating, or moodiness.

Ovulatory Dysfunction Overview

Ovulatory problems account for 20 to 30% of infertility cases.

A normal adult women ovulates every 25 to 32 days. Ovulation is actually a process of maturing eggs that have been “resting” in the ovaries since birth. Each day throughout a woman’s life until she reaches menopause, a few eggs move from the “resting” state into an “active” state. Even though eggs attempt to become “active” continuously through childhood, they can not mature since there are no hormones to drive their development. Hormones that can allow the “activated” eggs to mature only become available after a women reaches puberty. Once the eggs begin to mature they compete with each other to become “the” egg that will ovulate. After eggs commit to the maturation process, there is no turning backwards, they either achieve successful ovulation or they die.

Ovulatory Dysfunction Causes
Prematurely Aging Ovaries
The aging ovary is the most common cause of ovulatory problems. In the 10 years before menopause fewer and fewer eggs are present in the ovaries. When the remaining eggs fall below a critical level, cycles can become irregular. Eggs that mature during the last decade of reproductive life, are not as likely to establish a continuing pregnancy. For women who experience irregular cycles secondary to ovarian aging, it may be necessary to use much more fertility medication to achieve ovulation. 

Some women have irregular menstruation because their ovaries produce too much androgen (male hormones). These women are often overweight, and have a history of irregular periods, acne, and infertility. This syndrome has been called the Polycystic ovary syndrome(PCO), because of the multiple small follicle cysts that can be seen on ultrasound lined up just under the surface of the ovary. In some cases the excess male hormone does not represent PCO. The adrenal gland or the ovary may be sources of abnormal androgen production. Some of these conditions may be dangerous and require further investigation and treatment.Women who do have PCO may benefit by using insulin sensitizing medications, like metformin (Glucophage). Clomiphene citrate (Clomid) is the most common medication used to treat ovulation abnormalities among women with symptoms of PCO. Sometimes these two drugs can be used simultaneously. Your doctor will usually first give you medication such as medroxy-progesterone (Provera) to induce menses. After menstrual flow begins, clomiphene citrate is taken daily from the 3 rd through the 7 th day of the cycle. Patients may need clomiphene citrate doses of up to 5 pills per day to induce ovulation. It is helpful to monitor the response to this treatment. Acceptable ways of monitoring range from following basal body temperature charts and urinary ovulation predictor kits to daily sonogram monitoring and blood tests.

Physical or mental stress can result in ovulatory problems. It is not unusual for college or professional school students to stop ovulating. Extreme weight loss, exercise training, even preparation for a piano recital can all result in ovulatory problems. In many cases, these problems are temporary and normal cycling returns when the stressor is no longer present. For women with extreme weight loss an internist, reproductive endocrinologist and psychologist or psychiatrist are often all needed to help correct the problem. Although one could treat this type of anovulatory problem with fertility drugs, most people believe that it is safer and more effective to correct the underlying stressor.

If a woman has either an underactive or over active thyroid (Hypo or Hyperthyroidism) ovulatory problems may occur. Proper treatment of the thyroid abnormality will often restore ovulation.

Prolactin is a pituitary hormone that is normally secreted during and after pregnancy to prepare a woman’s body to produce milk for her baby. Sometimes too much prolactin is secreted from the pituitary when a woman is not pregnant. Not surprisingly, women with this condition often begin to lactate. Discharge of milk and loss of menstruation are the major symptoms associated with this condition. In some cases menses do not stop, but cycles become irregular and there is a shorter interval between menses. Women with this condition need to have a CT scan or MRI to make sure their pituitary is normal. Although in the past these cases sometimes required pituitary surgery, today excess prolactin production can almost always be effectively treated with medication.

Abnormal ovarian development
Some women are born with ovaries that can not produce eggs. Women with this condition do not go through puberty and usually never have a period.

Ovulation Dysfunction Treatment
The good news is that many ovulatory problems can be effectively treated. Once ovulation is restored the chance of pregnancy returns to normal. We are fortunate today that the availability of egg donors can provide an opportunity even for women with ovarian aging or abnormal ovarian development to achieve pregnancy.

The medications used to treat ovulatory problems will depend on their cause. Some medications are known as fertility drugs. These medications are oral medications like clomiphene citrate and injectable medications such as recombinant FSH, highly purified FSH, human menopausal gonadotropins, and human chorionic gonadotrophins. A special class of medications, such as bromocriptine or cabergoline, is used to treat hyperprolactinemia.