Ovulation is a necessary event for pregnancy to happen. Problems with the ovulation process account for 20-30% of all infertility cases. For normal ovulation to occur, a sequence of signals between the hypothalamus (an area at the base of the brain) and the pituitary gland initiates the release of follicle stimulating hormone (FSH) from the pituitary. FSH hormone stimulates the growth of eggs within the ovary until they are ready for ovulation. When an egg reaches maturity and is ready for ovulation to occur, the hypothalamus signals the pituitary gland to release a second hormone - Luteinizing hormone (LH) - which causes the final maturation and release of the egg 24-36 hours later. The site of ovulation becomes the Corpus Luteum. It produces progesterone which prepares the lining of the uterus for embryo implantation.

FSH injections (Follistim, Gonal- F, Repronex, Menopur and Bravelle) can be given to stimulate the ovaries to produce multiple eggs during In Vitro Fertilization  (IVF).

What are the causes of ovulation disorders?

Any disruption of the hormonal signals necessary for the development of healthy eggs can result in ovulation disorder. The important thing is that once your doctor identifies the cause for the ovulation problem, proper treatment can result in an excellent pregnancy rates.

In other patients the ovulatory disorder may be caused by stress, excessive exercise, and smoking or by abnormal thyroid hormones. Thyroid medication is often prescribed when an underactive thyroid is the problem.

Ovulation problems can present in several ways. Sometimes a woman has no menses at all (amenorrhea). At other times she may ovulate only sporadically decreasing her chances for pregnancy.

Treatment of ovulation disorders

If ovulation dysfunction is the only infertility factor, treatment with Clomiphene citrate (Clomid, Serophene) can restore normal ovulation in about 80% of the patients. And of those that do ovulate, about 40% will conceive after three cycles of treatment. Side effects attributed to the medication occur in less than 10% of patients and include hot flushes, breast tenderness, and abdominal pain as a result of enlargement of the ovaries. There is also an increased incidence of twins (7%) when more than one egg is released.  You are not a good candidate for Clomiphene treatment if:

When treatment with Clomiphene Citrate fails to restore ovulation or if you have low pituitary FSH level, you may be considered for Gonadotropin therapy. With this treatment expect to receive daily injections of fertility medication for about 10 days. During the treatment you will have several ultrasounds and blood estrogen measurements to check on the developing eggs and to make sure that the lining of the uterus is thick enough to support a pregnancy. If the estrogen level is too high, the dose of the fertility medication can be adjusted to prevent too many eggs from developing, as this may increase the risk of multiple pregnancies. Once the follicles containing the eggs measure about 18-20 mm by ultrasound, an HCG injection will be given to trigger the ovulation which will occur 36-40 hours later. Insemination with your husband’s sperm will be scheduled at the time of ovulation to maximize the number of sperm reaching the egg, thus increasing the likelihood for pregnancy. The pregnancy rates from this treatment range between 40-90% after six treatment cycles depending on the cause of the ovulation problem.

What are the risks of ovulation induction treatment?

As with any medical treatment, there are some risks specific to fertility medications. The most serious complications of ovulation induction occur with gonadotropin injection therapy.

• Multiple pregnancy - (mostly twins) occur in approximately 20% of ovulation induction cycles utilizing gonadotropin injections.  Careful monitoring of the developing eggs by ultrasound and blood tests can lower the risk of multiple pregnancies. When a triplet or higher order pregnancy occurs, reducing the pregnancy to twins (selective Reduction) is a consideration.
• Cycle cancellation  - Gonadotropin injections are discontinued and ovulation is prevented when there are too many eggs developing, increasing the risk of multiple pregnancies.
• Ovarian Hyperstimulation Syndrome  (OHSS) - is a potentially life threatening complication resulting from overstimulation of the ovaries, requiring hospitalization and aggressive treatment. The condition is associated with ovarian enlargement, torsion (twisting) of the ovaries, weight gain, accumulation of abdominal fluid, decrease of blood volume and low blood pressure. OHSS may occur even with mild stimulation. Fortunately, the severe form of Ovarian Hyperstimulation Syndrome is uncommon, occurring in less than 1% of patients.

What is poor ovarian reserve?

In older women, problems with ovulation may result from normal” aging” of their eggs. And when their eggs are depleted, they stop having periods altogether (menopause). Other women may experience menopause at younger age (Premature Ovarian Failure). The status of the ovaries (ovarian reserve)  can be determined by ultrasound and blood tests for Follicle Stimulating Hormone (FSH), inhibin and estradiol on day 3 of the menstrual cycle. For such patients treatment with ovulation inducing medications is inappropriate and In Vitro Fertilization (IVF)  with donated eggs from younger women, adoption or surrogacy  should be considered instead. Delivery rates for donor egg IVF  exceed 50%.