Diagnosing & Treating Infertility caused by Ovulatory Dysfunction and Premature Ovarian Failure
Ovulatory dysfunction is comprised of a variety of different conditions that each result in the same outcome – either irregular ovulation or the total lack of ovulation. The major symptom of ovulatory dysfunction is a history of irregular menstrual cycles. Most ovulatory menstrual cycles are regular, occurring every 27-30 days or so, and are accompanied by some mild uterine cramping. Most ovulatory patients also experience some breast swelling and/or tenderness in the few days leading up to the onset of menstrual bleeding, and many patients may also have some mid-cycle discomfort (“mittleschmertz”) that occurs around the time of ovulation. Women with ovulatory dysfunction, on the other hand, frequently have very irregular cycles, ranging from 30-90+ days in length, rare menstrual cramping, and no mid-cycle discomfort. They may have other symptoms as well, such as a milky breast discharge and/or an increase in hair growth – predominantly on their face, chest, or back.
A patient’s clinical presentation and laboratory evaluation will help the physician determine the cause of the ovulation disorder. The initial workup of ovulatory dysfunction includes an evaluation of thyroid function and a measurement of the pituitary hormone prolactin. It is important that the prolactin determination be performed on a blood sample obtained early in the morning while fasting. The most common ovulation disorders include hyperprolactinemia, hypothyroidism, polycystic ovarian syndrome, hypothalamic dysfunction, and impending ovarian failure.
Women who have elevated prolactin levels leading to ovulatory dysfunction initially need an evaluation of the pituitary gland to exclude a tumor as the source of the excess prolactin production. Pituitary tumors responsible for excessive prolactin production are essentially always benign, and they are usually treated with a category of medications called dopamine agonists. The most common medications are bromocriptine (ParlodelTM) and cabergoline (DostinexTM). Patients with thyroid disorders – most commonly hypothyroidism – are typically treated with thyroid replacement therapy.
Hypothalamic dysfunction or hypothalamic amenorrhea is an uncommon cause of ovulatory dysfunction. Oftentimes women with this condition are thin with a low percentage of body fat and have almost complete absence of menses when not on hormonal contraception or replacement. This can be due to excessive exercise or conditions such as anorexia nervosa, but is often present without an obvious cause. The evaluation of women with hypothalamic amenorrhea includes laboratory testing for the pituitary hormones FSH and LH, which are either in the normal range or low, as well as a serum estradiol level which is typically less than 10 pg/ml. On ultrasound evaluation, women with hypothalamic amenorrhea often have a very thin uterine lining and their ovaries may be small as well. Women with hypothalamic amenorrhea who are given progesterone to induce menses typically will not experience a period due to the absence of an estrogen-primed uterine lining. Women with hypothalamic amenorrhea will occasionally respond to clomiphene citrate for ovulation induction, but often need treatment with human menopausal gonadotropins (see gonadotropin stimulation).
Impending ovarian failure or premature ovarian failure has most recently been called primary ovarian insufficiency. Please refer to the appropriate section on our website for a complete discussion of this disorder.
Approximately 40% of the patients seen at the Texas Fertility Center have ovulatory dysfunction. Fortunately, this is one of the most easily treated conditions in our practice, and the overwhelming majority of patients with this disorder eventually do successfully conceive.