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Reproductive Endo/Infertility
Missouri Center for Reproductive Medicine and Fertility
Ovulation Disorder and PCOS

Ovulation is the monthly production and release of a mature oocyte (egg) from the ovary. Any disruption in this process may result in infertility. Problems with ovulation are usually seen in women who do not have regular menstrual cycles, although this can occur even in women with normal cycles. Some patients with irregular menses have Polycystic Ovarian Syndrome (PCOS). Criteria for the diagnosis of PCOS include 2 out of 3 of the following: (1) history of scant or no menses, (2) clinical and or biochemical signs of increased testosterone, (3) evidence of polycystic ovaries. Establishment of the diagnosis of PCOS also involves exclusion of various other disorders such as congenital adrenal hyperplasia, Cushing's syndrome, androgen secreting tumors, as well as thyroid or prolactin disorders which have a similar presentation. It is important to realize that patients with significantly abnormal menstrual cycles (i.e. periods every 3 months) do not need laboratory testing to determine if they are ovulating or not. Some of the ways to test for ovulation are listed below:

Basal Body Temperature (BBT) - a woman charts her temperature every morning before rising; approximately 2 days after ovulation, there is a sustained temperature increase of about 10 F. If pregnancy does not occur, the temperature goes back to baseline.

Urine LH testing - a woman tests her urine in the middle of her cycle for a hormone surge using a one-step over-the-counter ovulation predictor kit; ovulation usually occurs about 24-40 hours after the color change is seen.

Transvaginal Ultrasound - this is performed in the middle of the cycle prior to ovulation to confirm the presence of a dominant follicle (ovarian cyst with an egg inside); the thickness and pattern of the uterine lining can also be measured at this time.

Progesterone level - this is a hormone that goes up significantly only after ovulation occurs; it is a simple blood test that is performed about 1 week after ovulation.

Additional tests should be performed to evaluate patients who have irregular menstrual cycles. These are simple blood tests and include: 1) TSH (thyroid stimulating hormone) - to determine if the thyroid gland is functioning normally and 2) Prolactin - elevated levels of this hormone can be associated with ovulatory dysfunction.

In patients with excess facial or other hair, male hormone levels are usually obtained as well: 1) Testosterone 2) DHEAS. If PCOS is diagnosed your doctor may perform screening tests for pre-diabetic conditions and cholesterol abnormalities. You may also be encouraged to lose weight if your weight is higher than normal.

Ovarian Reserve Testing
Ovarian reserve refers to the ability of the eggs remaining in a woman's ovaries at a given age, to produce a viable pregnancy. This "reserve" may certainly decrease with age. We generally recommend testing on all women who are 35 y/o, as well as women with a history of poor response to fertility drugs. The two most established tests to evaluate ovarian reserve are:

Basal FSH, Estradiol - a single blood test that is performed between days 2 and 4 of the menstrual cycle; we routinely use this test.

Clomiphene Citrate Challenge Test (CCCT) - involves administration of clomiphene citrate, with 2 blood test measurements on day 3 and day 10 of the menstrual cycle; we use this test less commonly.

Basal Antral Follicle (BAF) count - Transvaginal ultrasound is performed to count the number of small follicles (cyst with egg inside) available for stimulation at the beginning of a treatment cycle {low number may indicate poor response}

Treatment for Ovulatory Disorder
In some patients with PCOS, weight loss can be associated with resumption of normal menstrual cycles; however, even with weight loss, fertility medication is still required in some women with PCOS. Both oral (pills) and injectable (shots) fertility medications can be used to help stimulate the ovaries to produce and release eggs. Fertility pills (clomiphene citrate or letrozole) require minimal monitoring, while patients receiving fertility shots (gonadotropins) require more frequent monitoring with ultrasound and blood tests.

Patients with PCOS also have problems with resistance to insulin, in addition to their ovulatory problems. Treatment with insulin-sensitizing agents such as Metformin, have been associated with weight loss, improved ovulatory function, and possibly a reduced rate of miscarriage.

Some patients who receive fertility medication will also undergo intrauterine insemination (IUI), a process by which sperm are specially prepared, and then injected into the woman's uterus in a simple office procedure. This can be done using either husband or donor sperm. Sperm preparation is performed in our Andrology Laboratory by highly trained andrologists, who utilize meticulous specimen handling and quality control measures to ensure safety.

Related Pages
Causes of Infertility
Infertility Evaluation
Ovulation Disorder and PCOS
Male Factor
Pelvic Factor
Unexplained Infertility
Tubal Reversal


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