Infertility due to ovulation problems Anovulation – “Egg release” or ovulation disorders

 

What is the definition of anovulation?

Very simple – the absence of ovulation. A common cause of anovulation is polycystic ovarian syndrome, PCOS.

Background on normal ovulation

  • The egg lives in an ovarian follicle until it is released at the time of ovulation
  • As a follicle grows in size during a menstrual cycle a fluid cavity enlarges in it
  • The egg is attached to the follicle wall
  • Ovulation is the process of rupture of the mature follicle and release of the egg
  • The fallopian tube is then supposed to pick up the egg and, if all goes well, the sperm and egg have a productive date in the woman’s fallopian tube

Ovary

 

Ultrasound picture of a polycystic ovary Many small, immature follicles (black circles) are seen These follicles are less than 10mm in diameter The follicles are not growing to a mature size
Normal ovary with a mature follicle Yellow cursors are measuring the mature follicle Fluid in the follicle is black on ultrasound Follicle is 18mm diameter – about ready for ovulation

In an average 28 day menstrual cycle, ovulation usually occurs on day 14, with day 1 being the first day of menstrual bleeding. If a woman has cycle lengths that are shorter or longer than 28 days, then the day of ovulation will usually be 14 days before her next period. So if she has a 26 day cycle length, then her ovulation should be on about day 12 and if she has a 32 day cycle, the ovulation is about day 18.

The length of time it takes a follicle to mature and ovulate is somewhat variable in different women (and in different cycles in the same woman), but the number of days from ovulation to the next period is much less variable and should be close to 14 days in everyone.

Fig-1-Representation-of-the-stages-of-follicle-development-from-the-non-proliferating

Developing follicle during a 28 day cycle with ovulation on day 14 Menstrual cycle days are shown at the bottom
  • Some women do not properly develop and release a mature egg every month – they do not ovulate regularly. We call this anovulation (lack of ovulation) – or oligoovulation (infrequent or irregular ovulation).

Some women never develop and release an egg without medication – we say they are anovulatory. These women have no menstrual periods for several months or years at a time. The medical term for this is amenorrhea – lack of menstrual periods. Often, when they do have a period it is quite heavy. In some cases, they may even require medical attention because of the degree of blood loss.

  • Some women ovulate occasionally (oligoovulation), for example, several times a year. They will often need medication to stimulate more regular egg development and ovulation to increase the chances for pregnancy.

 Major ovulation problem

  At this point, the problem is within the ovary itself e.g.

  • The ovaries were surgically taken out.
  • The ovaries were injured by radiotherapy or chemotherapy cure for cancer problems.
  • The ovaries do not have any eggs for example Turner Syndrome or merely possess just a few eggs inside them i.e. premature menopause which can affect 1-2% of females below the age group 40 years.
  • The female came into this world without ovaries.
  • Some females possess polycystic ovaries.

Minor ovulation problem

At this point, the ovaries are not the trouble, but the decrease of hormones produced from the pituitary gland or maybehypothalamus. Causes comprises of the following :

  • Severe stress and anxiety.
  • Recent tremendous increase or decrease of body weight.
  • Certain medications.
  • Tumor ( enlargement ).
  • Excess forming of the hormone prolactin (Hyperprolactinaemia).
  • Disturbances regarding the thyroid glands as well as the adrenal glands.

Luteal stage problem

This can be considered as sometimes a defect of Progesterone secretion by the Corpus Luteum or maybe a problem in the inner lining of the womb reaction to hormonal activation. This leads to an imperfect inner lining of the womb for embryo implantation. It is usually assumed that luteal phase defects has an effect on 3-20% of infertile partners.

Analysis of OvulationInitial Examination Essentially, the purpose of testing it to try to determine whether or not there exists normal discharge of an oocyte in a position to be fertilized, however clinical testing to identify ovulation is a lousy manual to oocyte standard. A comprehensive historical past will probably illustrate ovulatory medical disorder as amenorrhea, oligomenorrhea, dysfunctional uterine bleeding or even the existence of lactation with or just without cycle abnormalities. The occurrence of amenorrhea is nearly 3% in the people in general as well as among infertile partners. In case the history discloses responsible reasons, for example thyroid disease, hyperandrogenism, pituitary tumor, dietary malfunction, extremes of weight reduction and or physical exercise, hyperprolactinemia otherwise obesity (weight problems), these types of malfunctions has to be corrected. The exact reason for ovulatory dysfunction might stay unidentified, particularly in oligo-ovulation.

Starting laboratory check-up

Laboratory analysis most likely are not required in patients with temporary amenorrhea or oligomenorrhea ahead of initiation of a short course of treatment. In other patients, mid-luteal serum progesterone offers presumptive proof of ovulation. Mid-luteal progesterone levels above 10.0 ng/ml ( 30 nM/l ) are appropriate for the 10th percentile of progesterone concentration in cycles of pregnancy, however any specific level more than 5.0 ng/ml ( 15 nM/l ) is enough to reveal luteinization. In females over 35 years of age, or even individuals with a record of ovarian surgical treatment, FSH estimation on cycle day 3 is suggested to discard a poor ovarian response along with a decreased chance of pregnancy.

Continued analysis

Continued testing relies on which of four broad types of ovulation disorders could be presumed from the preliminary evaluation : hyperprolactinemic anovulation, hypergonadotrophic anovulation, hypogonadotrophic anovulation and also normogonadotrophic anovulation. Normogonadotrophic anovulation, as well as polycystic ovary syndrome, is regarded as the most common as well as the most challenging to deal with.

Hyperprolactinemic Anovulation

Prolactin and also thyroid-stimulating hormone must be examined in females with ovulatory disorders and also lactation. When ever recurrent prolactin levels are more than normal, and primary hypothyroidism has been ruled out, pituitary magnetic resonance imaging is suggested to rule out microadenoma, empty sella syndrome or even a macroadenoma. Even mildly raised prolactin levels might be an indication of one more organic central nervous system lesion, for examplecongenital aqueductal stenosis, non-functioning adenomas or just factors, which result in pituitary stalk irritability. Since the connection between pituitary tumor and level of prolactin is not strong, MRI (Magnetic resonance imaging) must not be limited to particular threshold levels, however must be carried out every time prolactin levels are above normal.

Hypergonadotrophic Anovulation

This group is referred to as WHO Type III anovulation. In case the FSH value is raised in a female with oligo-amenorrhea, the less likely chance of a arbitrary ovulatory peak needs to be neglected by making certain two values are attained around 10 days apart. Sometimes, FSH levels in the beginning vary in a high range after which increase to the menopausal range. In females under 30 with premature ovarian failure, a karyotype must be achieved to discard mosaic XY cell lines as well as other sex chromosome abnormalities, for instance translocation or short arm deletion. Raised FSH levels and premature ovarian failure are generally more widespread in ladies who are cases of the premutation ofFragile X syndrome.

Hypogonadotrophic Anovulation

This group is known as WHO Type I Anovulation. Weight reduction, undernourishment and also too much workout lead to hypogonadotrophic anovulation, and also guidance might be helpful. Forecasts of thyroxine-stimulating hormone and also prolactin levels are mentioned. The time period of the amenorrhea as well as the clinical condition are more beneficial symptoms of endogenous estrogen production compared to estradiol estimation, progesterone challenge testing or cervical mucus assessment. Whenever stress, weight reduction and also too much workout are not likely to result in the amenorrhea, Magnetic Resonance Imaging (MRI) might be mentioned to discard organic disease.

Normogonadotrophic Anovulation

This group is known as WHO Type II Anovulation. Research must consist of testosterone as well as sex hormone-binding globulin estimation (SHBG), along with ovarian ultrasound. In a survey which examined many medical as well asendocrine variables (factors), there have been 3 important predictors of good results with induction of ovulation : lower free androgen index, lower BMI along with a history of oligomenorrhea instead of amenorrhea. Polycystic ovary syndrome (PCOS) is among the most widespread element of this group and also requirements with this diagnosis entails any two of the following : cycle abnormality, androgen excess and ovarian ultrasound abnormality. Hence, PCOS entails females with bleeding intervals higher than 35 days, proof of raised androgen (hirsutism or raised free androgen index (FAI): >4.5  [FAI=testosterone 100/SHBG]) or polycystic ovary morphology on ultrasound ( ovarian volume>10 ml and/or follicle number>12/ovary in at least one ovary)

Further assessments

Basal temperature records, endometrial biopsies and also clomiphene citrate challenge testing will no longer be suggested for routine investigations of the infertile couple. Maintaining a basal temperature document is not necessary in females with normal menstrual cycles that can be a disturbing duty. Endometrial biopsy is an agonizing check, that has already been superseded for verification of ovulation by mid-luteal progesterone evaluation. The test is not exact in assessing an out-of-phase endometrium, as well as in any specific case, luteal phase defect is much more widespread among fertile females. The clomiphene challenge check offers no longer accuracy in the evaluation of ovarian reserve than basal FSH. Finally, luteinized, unruptured follicles, that are more popular in females using non-steroidal, antiinflammatory agents, are really not repeated which is not likely to be a reason for infertility.

Polycystic ovarian syndrome, PCOS

Polycystic ovarian syndrome is a very common cause of anovulation, or oligoovulation andinfertility.

Picture of polycystic ovary at laparoscopic surgery Picture of mature ovarian follicle at laparoscopy
Laparoscopic image of an enlarged,
polycystic ovary. No mature follicle seen.
Picture of a normal ovary close to ovulation
Mature follicle seen above the X
(looks like a blister)
U= uterus, T = tube

Treatment of ovulation problems and polycystic ovaries

  • In general, cumulative pregnancy success rates are high with treatment from a fertility specialist when the fertility issue is an ovulation problem.
  • If the female age is under about 37, it is usually more a matter of which fertility medications and treatments will end up being successful – rather than whether anything will ever work.