Anovulation affects between 6% and 15% of all women of childbearing age. During the first two years after menarche 50% of the menstrual cycles could be anovulatories. In addition to the alteration of menstrual periods and infertility, chronic anovulation can cause or exacerbate other long term problems, such as polycystic ovary syndrome.
It is in fact possible to restore ovulation using appropriate medication, and ovulation is successfully restored in approximately 90% of cases.
The first step is the diagnosis of anovulation. Temperature charting is a useful way of providing early clues about anovulation, and can help gynaecologists in their diagnosis. The identification of anovulation is not easy; contrary to what is commonly believed, women undergoing anovulation still have (more or less) regular periods. In general, patients only notice that there is a problem once they have started trying to conceive.
Hormonal or chemical imbalance is the most common cause of anovulation and is thought to account for about 70% of all cases. About half the women with hormonal imbalances do not produce enough follicles to ensure the development of an ovule, possibly due to poor hormonal secretions from the pituitary gland or the hypothalamus. The pituitary gland controls most other hormonal glands in the human body. Therefore, any pituitary malfunctioning affects other glands under its influence, including the ovaries. This occurs in around 10% of cases. The mammary glands are also controlled by the pituitary gland, so lactation can also be affected. The pituitary gland is controlled by the hypothalamus. In 10% of cases, alterations in the chemical signals from the hypothalamus can easily seriously affect the ovaries. There are other hormonal anomalies with no direct link to the ones mentioned above that can affect ovulation. For instance, women with hyper or hypo-thyroidism sometimes have ovulation problems. Thyroid dysfunction can halt ovulation by upsetting the balance of the body’s natural reproductive hormones. Polycystic ovary syndrome (also known as Stein-Leventhal syndrome) and hyperprolactinemia can also cause anovulatory cycles through hormonal imbalances.
Classification
According the World Health Organization (WHO) criteria for classification of anovulation, (which include the determination of oligomenorrhea or amenorrea in combination with concentration of prolactin, follicle stimulating hormone and estradiol) the patients are classified as:
The vast majority of anovulation patients belong to the WHO2 group and demonstrate very heterogeneous symptoms ranging from anovulation, obesity, biochemical or clinical hyperandrogenism and insulin resistance.
Associated diseases
Complications
Anovulation can result in a number of health complications, especially if it is left untreated.
Functional problem
This accounts for around 10-15% of all cases of anovulation. The ovaries can stop working in about 5% of cases. This may be because the ovaries do not contain eggs. However, a complete blockage of the ovaries is rarely a cause of infertility.
Risk factors
An anovulatory cycle is a menstrual cycle during which the ovaries do not release an oocyte. When a woman is anovulatory, she can't get pregnant because there is no egg to be fertilized. Women who are anovulatory have irregular, few or no periods.
This is common in women from their mid-thirties, but research has found that increasingly younger women are also suffering from these cycles. In fact, about 40 % of infertility in women is related to cycles that don't ovulate.
Several studies indicate that in some cases, a simple change in lifestyle could help patients suffering from anovulation. Consulting a nutritionist, for example, could help a young woman suffering from anorexia to put on some weight, which might restart her menstrual cycle. Conversely, a young overweight woman who manages to lose weight could also relieve the problem of anovulation (losing just 5% of body mass could be enough to restart ovulation).
Anovulation is usually associated with specific symptoms.
Some cases of anovulation can be treated by lifestyle change or diet.
Chinese/East Asian medicine
Acupuncture and other modalities of Chinese/East Asian medicine have been used to treat women's health for many centuries. Gynecology specialties focus particularly on menstrual and reproductive disorders. Acupuncture may positively influence ovulation and fertility.
Clomifene is useful in those who are infertile due to anovulation or oligoovulation. Evidence is lacking for the use of clomifene in those who are infertile without a known reason. 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. Clomifene has also been used with other assisted reproductive technology to increase success rates of these other modalities.
Oral antidiabetic agents
Metformin
Metformin was recommended as treatment for anovulation in polycystic ovary syndrome.
Selective estrogen receptor modulator (SERM)
Tamoxifen
Tamoxifen may be used an alternative to clomiphene citrate for ovulation induction in women with anovulatory infertility. A dose of 10–40 mg per day is administered in days 3–7 of a woman's cycle.
Gonadotropins
A molecule which is structurally similar to luteinizing hormone (LH). LH is secreted by the pituitary just before ovulation occurs, whereas hCG is released during pregnancy. On its own, hCG is not very effective in inducing ovulation, but when combined with clomifene citrate, it is much more effective.
2. Human menopausal gonadotropin (hMG)
A very powerful treatment for infertility. It consists of a combination of LH (luteinizing hormone) and FSH (follicle-stimulating hormone). From menopause onwards, the body starts secreting LH and FSH in large quantities due to the slowing down of the ovarian function. This excess of hormones is not used by the body and is expelled in the urine. HMG is therefore collected from the urine of menopausal women. The urine then undergoes purification and a chemical treatment. The resulting hMG induces the stimulation of several ovarian follicles. This increases the risk of producing several oocytes during the same cycle, and thus the risk of multiple pregnancies.
3. Follicle-stimulating hormone (FSH or recombinant FSH)
Now used as a replacement for hMG (human menopausal gonadotropin). Although hMG is a combination of FSH and LH (luteinizing hormone), FSH is the only active component that has an effect on ovulation. However, until recently, it was not possible to produce pure FSH. FSH is now administered in a similar way as hMG, at a specific point during the cycle, and it requires medical monitoring. It is therefore important to fully understand a woman’s cycle, and to be able to accurately anticipate menstruation and ovulation dates. FSH is also sometimes useful for women who are suffering from PCOS (Polycystic ovary syndrome).
Surgical therapy
Surgical therapy is usually indicated to resolve the underlying cause for the anovulation (e.g. fallopian tube obstruction), typically when medical therapy has failed. Surgical treatment is also needed in uncommon cases, such as a macroadenoma of the pituitary with unrelenting growth eliciting acute symptoms (eg, headaches, bitemporal hemianopsia, diplopia).
Surgery can be attempted in case of inefficient result with medications for ovulation induction. Though surgery is not commonly performed, the polycystic ovaries can be treated with a laparoscopic procedure called "ovarian drilling"(puncture of 4-10 small follicles with electrocautery), which often results in either resumption of spontaneous ovulations or ovulations after adjuvant treatment with clomiphene or FSH.
For patients who do not respond to diet, lifestyle modification and clomiphene, in vitro fertilisation (IVF-ICSI) can be performed. This usually includes controlled ovarian hyperstimulation with FSH (follicle-stimulating hormone) injections, and oocyte release triggering with human chorionic gonadotropin (hCG) or a GnRH (gonadotropin-releasing hormone) agonist.
An eating disorder characterized by the maintenance of a body weight below average, fear of gaining weight, and a distorted body image.
A disease of excess body fat that can have a negative effect on health, leading to reduced life expectancy and other health problems.
A condition in which a woman has an imbalance of female sex hormones. This may lead to changes in the menstrual cycle, cysts in the ovaries, trouble g
An abnormal condition in a woman's menstrual cycle.
A medical condition impairing the function of the thyroid.
Turner syndrome is a genetic disorder in which a female is partly or completely missing one X chromosome that results in ovarian dysgenesis.
The loss of function of the ovaries before age 40.
A medical term which describes a diminished functional activity of the gonads – the testes and ovaries.
Cancer that arises from the endometrium, the lining of the uterus.
The absence of a menstrual period in women of reproductive age.
Light or infrequent menstrual flow at intervals of 39 days to 6 months or 5–7 cycles in a year.
A condition of low fertility characterized by low numbers of remaining oocytes in the ovaries or possibly impaired oocyte development or recruitment.
Condition that occurs due to excessive production of thyroid hormone by the thyroid gland.
The presence of abnormally high levels of prolactin in the blood.
The luteinisation of ovulatory follicle without a release of an oocyte.
A pituitary malfunction is a disorder affecting the pituitary gland, either by overproduction or underproduction any of pituitary gland hormones.
Group of diseases, which have impact on function of hypothalamus.
Excess levels of insulin circulating in the blood relative to the level of glucose and impairing the hormonal levels, even those involved in reproduct
A region of the forebrain that regulates body temperature, some metabolic processes and governs the autonomic nervous system.
The ovum-producing organs of the internal female reproductive system
An endocrine gland, about the size of a pea, whose secretions control the other endocrine glands and influence growth, metabolism, and maturation.
A group of granulosa cells that support the oocyte in an antral follicle.
A female germ cell involved in reproduction.
FSH is a hormone secreted by the anterior pituitary gland. It regulates the development, growth, pubertal matur and reproductive functions of the body
A releasing hormone responsible for the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary.
The fusion of an ovum with a sperm to initiate the development of a new individual organism.
Development of ovarian follicles from primordial to tertiary under the stimulation of gonadotropins.
The very early stage of pregnancy at which the embryo adheres to the wall of the uterus.
The process of the maturation of the female gametes through the meiotic division.
The release of egg(s) from the ovaries.
Disorder characterized by symptoms of both anxiety and depression that may cause sexual disorders and anovulation.
A patterned use of a drug in which the user consumes the substance in amounts or with methods which are harmful to themselves or others.
A mental disorder defined by abnormal eating habits that negatively affect a person's physical or mental health.
The toxic effect of certain metals in certain forms and doses on life.
The presence of abnormally high levels of prolactin in the blood.
A condition characterized by excessive levels of testoterone in the body.
A diminished level of blood estrogen level.
Eating habits are one of the few factors within our control that impact not only our chances of falling pregnant.
Type of lifestyle with no or irregular physical activity.
Long-lasting inhalation of the smoke of burning tobacco.
Toxins are small molecules, that are capable of causing disease on contact with or absorption by body tissues interacting with biologic macromolecules
Underweight is a term describing a person whose body weight is considered too low to be healthy
The absence of a menstrual period in a woman of reproductive age.
The emotional state characterized by unpleasant feelings such as uneasiness, worry, apprehension and dread.
A medical condition most frequently related to females.
A condition of low serum levels of estrogen.
The emotional state characterized by persistent feel of low self-esteem, loss of interest, sadness and negative attitude.
The condition when there are elevated levels of insulin within the blood in relation to levels of glucose.
The presence of abnormally high levels of prolactin in the blood.
The presence of elevated testosterone concentration within the circulating blood.
The excessive hairiness on women in those parts of the body where terminal hair normally is absent or minimal, such as a beard or chest hair.
The medical term for infrequent, often light menstrual periods (intervals exceeding 35 days).
Irregular menstruation is a menstrual disorder whose manifestations include irregular cycle lengths as well as metrorrhagia
Body weight that's greater than what is considered healthy for a certain height.
A combination of physical and emotional disturbances that occur after a woman ovulates and ends with menstruation.
A medical condition that affects the function of the thyroid gland.
A term describing a person whose body weight is considered too low to be healthy.
A form of alternative medicine and a key component of traditional Chinese medicine involving thin needles inserted into the body at acupuncture points
Process by which a woman donates eggs for purposes of assisted reproduction or biomedical research.
A micromanipulative fertilization technique in which a single sperm is injected directly into an egg.
The way a person lives.
It is a therapeutic approach to treating medical conditions and their associated symptoms via the use of a specifically tailored diet.
A surgical treatment that can trigger ovulation in women with polycystic ovary syndrome (PCOS).
Physical exercise is any bodily activity that enhances or maintains physical fitness and overall health and wellness.
The procedure in which a man (sperm donor) provides his sperm for fertility treatment.
A process in which an egg is fertilised by sperm outside the body: in vitro. Own or donated gametes may be used.
A broad range of medicine practices sharing common concepts which have been developed in China and are based on a tradition of more than 2000 years.
A physical, mental, and spiritual practice or discipline which originated in India.
