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 10pg/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.
