Approximately 15 % of infertility is secondary to ovulatory dysfunction. It is very important to figure out what the dysfunction is, as different causes have different treatments.
First and foremost comes obtaining adequate information from a patient’s history. If a woman is having irregular periods or lack of periods or bleeding all the time, she is likely not ovulating in a normal manner. Some of the things that can impact ovulation are abnormalities in thyroid function (hypothyroidism or hyperthyroidism), high levels of the hormone prolactin hyperprolactinemia), polycystic ovary syndrome (PCOS), lack of appropriate hormone production from the brain (hypothalamic amenorrhea), obesity, premature ovarian failure and also things like eating disorders and extreme stress. It is very important for us as physicians treating infertility to differentiate between the various etiologies so that we may appropriately select the form of treatment.
Things such as thyroid disorder are easily treatable via synthetic thyroid hormone replacement if low or other modalities if high. Often normalizing thyroid function will cause normalization of the ovulatory function. For women with PCOS, often medications to induce ovulation such as Clomid, letrozole (Femara) or gonadotropins are of benefit. The oral medications such as Clomid and Femara are first line since they are easy to use, have low side effects, they are inexpensive, and risk of multiples is also low. Many women with PCOS are obese and have glucose intolerance. Such women would benefit from weight loss and use of a medication called Metformin which improves the sensitivity to the actions of insulin in the body. In general if someone is going to get pregnant with oral medication, 85% of the pregnancies will happen within the first 4 cycles, after which it would be of benefit to consider other options.
For women with hypothalamic causes of ovulatory dysfunction, they are most likely to have success with the gonadotropin injections. Those women who have premature ovarian failure (i.e. premature menopause), unfortunately there are not any good options other than IVF with donor egg. For those women with hyperprolactinemia, an MRI of the brain is necessary to see if they have a benign tumor of the pituitary gland called prolactinoma. If the tumor is small, it can be treated with oral medications which will normalize the hormone levels and often result in return of normal ovulation. Of course healthy lifestyle, good eating habits, maintaining a normal weight and minimizing stress as much as possible may also be of benefit with respect to fertility.
As you can see, there is no “one size fits all” when it comes to fertility and ovulatory dysfunction, at TFC we try very hard to determine the root of the problem and tailor treatment to have the best outcome for each individual patient.
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