Discussions on "Ovulation Disorder" in "Trying to Conceive" forum.
5th Jun 2012, 09:19 PM #1
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Ovulation Disorders Anovulation and ovulatory disorders are present in up to 20% of infertile couples. Recent advances in reproductive endocrinology have made ovulation induction one of the most successful areas in treating the infertile couple. Using the various therapeutic modalities available today, ovulation can be achieved in greater than 90% of women with at least 75% of women becoming pregnant.
DETECTION OF OVULATION
A disorder of ovulation is readily apparent if a woman has no menses or menses are quite irregular, but requires closer scrutiny in women with regular menses. Pregnancy is the only guarantee that a normal ovulation has occurred.
All other tests assess various changes associated with ovulation but can not guarantee the oocyte was released from the ovary and that luteal phase ovarian function (progesterone production) was normal.
Basal body temperature charts are an inexpensive means of ovulation detection but are inaccurate.
Ovulation can now be predicted by at-home kits that measure luteinizing hormone (LH) in the urine.
Midluteal phase (a week before menses) measurement of serum (blood) progesterone concentrations remains the simplest and most accurate method of detecting ovulation.
Serial pelvic ultrasounds are currently the most accurate noninvasive method of ovulation detection. But even ultrasound is not the perfect test due to the variable ultrasonic appearance of the ovary after ovulation and documentation of retained oocytes in follicles that have collapsed on ultrasound.
The existence of low progesterone production (luteal phase defects, LPD) as a physiologic entity is well accepted, but the clinical significance of LPD as related to infertility or recurrent pregnancy loss remains controversial. LPD probably represents a subtle ovulatory defect found in a " gray zone" on the spectrum of ovulatory function between anovulation and normal ovulation.
Many tests have been used to evaluate the luteal phase.
The three most commonly used are basal body temperature (BBT) charts, progesterone concentrations, and endometrial biopsies.
BBT charts are used to estimate the time from ovulation to menses. Luteal phase length of 11 days or more is present in 95% of women. Progesterone levels of 2.5 ng/ml will result in temperature elevation. However, the BBT has been an insensitive indicator of LPD (luteal phase defect) in many studies. No correlation has been confirmed between a slow rise in temperature and pregnancy.
Progesterone levels above 3-5 ng/ml probably represent a functioning corpus luteum and levels above 8-9 ng/ml predict normal fertility. The actual minimum level required for fertility is not defined and has been estimated anywhere from 8 to 20 ng/ml. There is poor correlation between the appearance of the endometrium on biopsy and progesterone levels. Several factors can induce variability in progesterone levels including pulsatile secretion of progesterone, exercise, and eating.
An endometrial biopsy showing a lag in endometrial development of greater than 2 days in two menstrual cycles is the most widely accepted diagnosis of a LPD. Unfortunately the endometrial biopsy has also been subjected to much criticism for its lack of reproducibility, expense, invasiveness, cycle-to-cycle variation, interobserver variance, and most importantly its lack of predictive value.
The absence of a precise and noninvasive test of luteal function, and the fact that treatment of women with the clinical diagnosis of LPD can result in a substantial pregnancy rate have lead to the common use of empiric ovulation induction in women suspected of having LPD.
5th Jun 2012, 09:19 PM #2
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Re: Ovulation Disorder
Accurate diagnosis of the anovulatory disorder is critical for the proper choice and use of a therapeutic regimen. The initial step in discovering the cause of ovulatory dysfunction is an evaluation by your physician. The physician will review your history for potential symptoms and will perform a physical exam. The history should begin with a complete menstrual history. Important facts include when menses and breast development began, previous menstrual irregularity, sexual and contraceptive history. A history of previous pelvic surgery or family members with no menses should be investigated. Other symptoms which can help establish the diagnosis are: marked weight gain or loss, a diet history including signs of anorexia or bulimia, recent stressful events, increased amounts of exercise, hot flushes, dry vagina, excessive hair growth, acne, and lowering of the voice. Headache is the most common symptom in patients with prolactin-secreting pituitary adenomas. Other symptoms and causes related to high prolactin levels include: breast discharge, visual changes, stress, frequent self-breast examination, and a positive drug or medication history.
A complete physical examination must be performed including assessment of nutritional status, blood pressure, hair pattern, breast discharge, signs of thyroid or adrenal disease and a complete pelvic examination.
TSH (thyroid stimulating hormone) and prolactin are the only tests that need to be ordered in all amenorrheic patients. Hypothyroidism is a rare cause of amenorrhea, but is easily missed unless TSH concentrations are evaluated. Before the diagnosis of hyperprolactinemia is made, the prolactin concentration should be checked twice. Transient elevations of prolactin in normal women are very common. Evaluation of TSH in hyperprolactinemic women is particularly important since primary hypothyroidism can clinically mimic a prolactin-secreting adenoma. If the prolactin level is high, the pituitary should be evaluated by computerized tomography or magnetic resonance imaging.
A common test for women with no menses is to try to start a menses by taking a progesterone-like drug, Provera. The Provera test evaluates the current status of estrogen production. Provera can be given orally as medroxyprogesterone acetate (10mg per day for 5 days) A positive test confirms the presence of some estrogen production, and that there is a uterus which is able to respond. Any vaginal bleeding represents a positive test. The work-up is now complete if the history, physical, and laboratory data are otherwise normal.
If signs of elevated male hormone levels (excessive hair growth or acne) or obesity are present serum concentrations of dehydroepiandrosterone sulfate (DHEAS) and testosterone should be evaluated. The most common diagnosis in this category is polycystic ovarian disease.
Women with no bleeding following the Provera test (progestin challenge negative) usually have a disorder of the pituitary or hypothalamus.
Elevated serum concentrations of FSH confirm ovarian dysfunction. Minimal elevations of FSH in women predict decreased fertility due to poor egg quality. Measurement of estradiol concentrations also on day 3 enhances the accuracy the FSH assessment. Very high levels of FSH can indicate premature menopause.
The semen analysis is the only infertility test required prior to ovulation induction. Serum progesterone concentrations and ultrasound should be performed during treatment to assess success of therapy. Hysterosalpingography and laparoscopy may be delayed until several ovulatory cycles do not result in pregnancy.
Ovulation induction is possible in the majority of anovulatory women after proper diagnosis and treatment selection. Clomiphene citrate remains the first choice for treatment in most anovulatory women. Appropriately timed adjunctive therapies can significantly improve the success rate with clomiphene citrate. Bromocriptine induces ovulation and assures a safe course through pregnancy in most women with hyperprolactinemia and prolactin-secreting adenomas. Gonadotropin therapy is effective for most women who do not respond to clomiphene citrate.
Pacific Fertility Center