Ovulation Dysfunction

Ovarian Factor Infertility, Ovulation Dysfunction

The female reproductive system is a complex interaction of many hormones including follicle stimulating hormone, luteinizing hormone, estrogen, progesterone, and many others. Multiple interrelated processes must occur correctly for the ultimate result of an “ovulated egg”. The hypothalamus is a small gland located at the base of the brain that coordinates hormone regulatory functions. It monitors the levels of various hormones and sends “instructions” to the pituitary gland via hormone mediators.

Follicle stimulating hormone (FSH) is secreted by the pituitary gland and causes the recruitment and development of ovarian follicles. During the first part of the menstrual cycle, levels of FSH increase to stimulate follicular development. The brain (hypothalamus) produces gonadotropin-releasing hormone (GnRH), which stimulates the pituitary to produce FSH.

As healthy follicles develop, they secrete increasing amounts of estrogen, which is monitored by the brain (hypothalamus).  Once the hormone levels indicate that the follicles are mature, the hypothalamus signals the pituitary to release a surge of luteinizing hormone (LH), which induces the final steps of egg maturation and triggers ovulation. Disruption of any of these processes can lead to irregular (oligoovulation) or no (anovulation) ovulation. Many conditions can lead to ovulatory dysfunction including polycystic ovarian syndrome (PCOS), thyroid disorders, ovarian failure, elevated prolactin levels, excessive exercise, and others. There are effective treatments for many of these abnormalities.

Irregular ovulation can be treated using several different fertility drugs. Clomid binds to estrogen receptors in the brain and deceives the brain into thinking that the estrogen levels are low, and correspondingly increases FSH production. FSH works to directly stimulate the recruitment and development of follicles (eggs) that make more estrogen.  Medications that improve insulin sensitivity (metformin) are often used alone or in conjunction with Clomid to induce normal ovulation.

Women are born with a lifetime supply of eggs and as they age the “quality” and “quantity” of their eggs declines, ultimately ending in menopause. Furthermore, some women experience premature ovarian failure seeing a decline in the number of available eggs while still in their twenties or thirties. Many women now delay childbearing until their careers are established and many couples are marrying at older ages. Specialists are seeing an increase in age related infertility due to these societal factors. In many cases these women with diminished ovarian reserve are candidates for our Texas donor egg IVF program.

One measurement of ovarian “quantity” or “reserve” is the Day 3 FSH level. In general, levels above 10 miu/ml are an indication of diminished ovarian reserve and dramatically reduced chances of “natural conception”. A more dynamic test to assess for ovarian reserve is the Clomid challenge test.  Testing is based on the principle that the pituitary gland will only make the least amount of FSH that is needed to stimulate the ovaries.  If the ovaries are highly responsive (“good ovarian reserve”), then the FSH level will be low, even when “challenged” by the fertility medication Clomid.  In patients with compromised ovarian reserve (low quantity of eggs), the pituitary gland will secrete more FSH, both in the basal state and after being challenged by Clomid. Women who fail the Clomid Challenge test are usually candidates for donor egg IVF.

Severely reduced ovarian reserve, or ovarian failure, can only be realistically treated with IVF using donor eggs in our Donor Egg Program. In this procedure, the egg donor undergoes fertility medication to super ovulate, and the harvested eggs are subsequently fertilized with the patient’s husband’s sperm.  Fortunately, pregnancy rates and live birth rates are high helping to control infertility treatment costs.