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Ovulatory dysfunction is a very common cause of infertility. Fortunately, in many cases the treatment is relatively easy to accomplish. A brief discussion of the physiology of this disorder and the treatment options are as follows.
In a normal menstrual cycle, the pituitary gland in the brain secretes follicle stimulating hormone (FSH), which in turn stimulates the growth of ovarian follicles, each of which contains an egg. As healthy eggs develop, they produce increasing amounts of estrogen, which gradually thickens the endometrium where the embryo will eventually attach.
When ovulation occurs, the dominant hormone from the ovary becomes progesterone. This hormone is generally secreted for two weeks. In the absence of a pregnancy, the progesterone levels eventually drop and menses ensues. One of the most accurate methods to determine if ovulation has occurred is to test the blood for this progesterone hormone.
If the progesterone level is determined to be low, ovulation is not occurring and the most likely reason will be a condition called polycystic ovarian syndrome (PCOS). PCOS is one of the most common causes of a lack of ovulation and one of the more common causes of infertility in general.
This abnormality is not completely understood, however, it is commonly associated with elevated insulin levels, which leads to increased androgen hormone production by the ovaries. These increased androgens contribute to irregular or absent ovulation. Please see our PCOS page for more information.
A less common cause for lack of ovulation is an elevation of a hormone called prolactin. High levels of prolactin are caused by small tumor at the base of the brain (pituitary gland). Most often these elevated prolactin levels are treated successfully with a medication called bromocriptine or cabergoline. Rarely, surgery is needed to remove the tumor and is a more common consideration when the tumor is particularly large. Once prolactin levels are normalized, ovulation typically resumes.
Fortunately there are many effective fertility medications, each of which is discussed in detail on the fertility drug web pages. Clomid is the first ovulation induction agent normally given. Clomid ultimately leads to increased production of FSH from the brain, egg recruitment, development and ultimately ovulation. It is usually effective in the first three cycles, but it's often tried for up to six months. Use of Clomid is generally discouraged beyond six months, unless it is being used in a limited sense when combined with intrauterine inseminations.
Letrozole has also been used recently as an ovulation induction agent. It blocks conversion of androgens to estrogen, which results in lower estrogen levels, which in turn causes increased FSH production and ultimately oocyte development.
Letrozole must be monitored more closely than Clomid cycles, as unintended administration during early pregnancy could have detrimental effects on a developing fetus. A careful and detailed discussion will be necessary with Dr. Bachus and he will discuss management strategies that should keep this outcome from occurring.
Some patients with the PCOS will respond to a medication called metformin. It is most commonly used in the management of diabetes, but has been shown to induce ovulation as well. It can have some undesirable intestinal side effects and Clomid has been shown to be more effective in the largest percentage of patients. Nevertheless metformin remains an excellent choice for a subset of patients.
If Clomid, letrozole, and metformin are unsuccessful, another medication in the form of purified FSH is sometimes necessary. This medication is administered by subcutaneous injection and unfortunately is considerably more expensive than the above noted medications. It also can elicit a very powerful response with the recruitment of multiple eggs.
Because multiple eggs can lead to multiple pregnancy (such as twins), FSH should be administered by a trained reproductive endocrinologist (infertility specialist) in an effort to minimize this occurrence. Cycles must be carefully managed with medication dosage adjustments as needed to minimize the risk of these multiple pregnancies and other complications.
Unfortunately, one of the reasons for a lack of ovulation occurs with the menopause. The menopause is defined as the interval of time when no eggs remain within the ovaries. The only treatment option for women with this condition is the use of donor eggs. Another scenario for the lack of eggs occurs following chemotherapy for cancer. Traditionally, the most successful treatment for this situation also involves the use of donor oocytes.
In an effort to avoid the consequences of oocyte depletion, some have advocated the use of egg freezing when an individual is young and healthy to be used at a later time in life if necessary. Cryopreservation of human oocytes is still a relatively new technology and long-term data on the effectiveness is not complete.
Successful pregnancies have been achieved for oocytes that were cryopreserved. While the pregnancy rates have not been especially high, they are gradually improving.
Some fertility clinics are aggressively promoting the cryopreservation of oocytes, but Dr. Bachus advises caution placing all hopes for family on this procedure at this point in time.
We provide services for the diagnosis and treatment of infertility.
Our services include an outstanding IVF and donor egg program.
We offer all levels of treatment including infertility testing intrauterine insemination (IUI), medical treatment, and advanced laparoscopic surgery. Most of our patients become pregnant without requiring IVF.
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Friday 8AM - 1PM
Our patients can reach us for emergencies 24 hours a day by calling our main number, and selecting choice #1, which pages our medical or nursing staff.
If your situation is life threatening, dial 911 or go directly to your local ER.