Ovulation Failure and Induction

Diagnosis, epidemiology, and genetics of the polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a heterogeneous disorder, and its definition remains fluid and controversial. PCOS is characterized by clinical and/or biochemical hyperandrogenism, and is frequently accompanied by ovulatory dysfunction and polycystic ovaries. PCOS is a diagnosis of exclusion, with other androgen excess and related disorders to be excluded. The prevalence of PCOS is 6.5-8.0% of unselected women of reproductive age, using the NIH 1990 criteria. Genetically, PCOS is a common, complex disorder. Despite repeated attempts to identify the putative gene or genes responsible for this disorder, the PCOS gene(s) remain elusive.

Common problems in induction of ovulation

There are many groups of women with anovulatory infertility who respond abnormally to conventional treatment. It is important to diagnose the underlying disorder correctly before commencing treatment. In this chapter we have discussed the various treatment modalities available and how they may be adapted to fit the particular clinical needs. In women who are profoundly hypo-oestrogenic, the 'priming' of the ovary using prolonged low-dose gonadotrophins offers a possible solution if both subcutaneous and intravenous pulsatile GnRH therapy has failed. It may also reduce the incidence of multiple pregnancies in these women. Growth hormone seems to augment the response to gonadotrophin in these women and may prove a useful adjunct to therapy once further experience of its use has been reported. Women with PCO have been a difficult group to treat because of their tendency to hyperstimulate. The low-dose gonadotrophin regimen outlined in this chapter overcomes the majority of these problems without reducing the rate of conception. This group continue to have an increased incidence of miscarriage. The introduction of combined therapy of hMG with a GnRH analogue may improve this situation, but the data from randomized controlled studies are still awaited. Ovarian failure remains an untreatable cause of infertility. A few women may become pregnant spontaneously, but these are the exception rather than the rule. Hormone replacement therapy should be offered to all these women because of the long-term problems of osteoporosis and cardiovascular disease. Products containing a low dose of oestrogen (e.g. Premarin 0.625 mg) will not interfere with ovulation if there should be a spontaneous resumption of ovarian activity.

Evaluation of the anovulatory patient. When to proceed, when to refer

The anovulatory patient presents the primary care physician with what is often a diagnostic and therapeutic challenge. To meet this challenge and avoid doing a disservice to the patient, the physician needs to have both a firm understanding of the disease process and an adequate understanding of available treatment methods. Anovulation must be considered before it can be recognized. Once it is suspected, a thorough yet judicious approach to diagnosis must be undertaken. In these days of diagnosis-related groups (DRGs) and prospective reimbursement, a thoughtful, logical, cost-effective approach to the diagnosis of anovulation is more critical than ever. Finally, once the diagnosis is achieved, investigation of the etiologic factor can proceed in an orderly, stepwise fashion. There is no place for a shotgun approach in the work-up of the anovulatory patient. Even more important to the primary care physician is a firm understanding of when to refer. While straightforward aspects of the patient evaluation are best accomplished at the local level (indeed, the tertiary care center could not and should not try to cope with total referral), complex diagnostic and therapeutic regimens should be handled by the reproductive endocrinologist. Patients with hyperprolactinemia, those who have failed ovulation induction with clomiphene citrate (Clomid), those with suspected outflow tract anomalies, and hypoestrogenic patients surely should be evaluated and treated in consultation with the specialist. This approach of careful, efficient initial assessment coupled with appropriate use of the reproductive endocrinologist and tertiary referral center leads to optimum care of the anovulatory patient.

Anovulatory and ovulatory infertility: results with simplified management

A simplified scheme for the management of anovulatory and of ovulatory (usually called unexplained) infertility was evaluated in 244 women. Eighteen patients were excluded because of primary ovarian failure, 164 were treated for ovulatory failure, and 62 with ovulatory infertility remained untreated. Twenty-five patients had a properly validated negative postcoital test. In the remaining 201 patients the two-year conception rates were 96% in patients with amenorrhoea, 83% in those with oligomenorrhoea, 74% in those with luteal deficiency, and 88% in those with ovulatory infertility. Comparison with normal rates implied that amenorrhoea represents a pure form of ovulatory failure that is completely correctable whereas in other conditions unexplained factors also contribute to infertility though to a much smaller extent than was previously thought.

The value of a single serum progesterone measurement in the midluteal phase as a criterion of a potentially fertile cycle ("ovulation") derived form treated and untreated conception cycles

A single midluteal serum progesterone concentration was obtained in 212 untreated cycles in 113 infertile patients, including 138 cycles in 72 patients in whom tubal, seminal, and cervical causes of infertility had been excluded. There were 16 conception cycles in the latter group. In an extended study a total of 21 untreated singleton conception cycles have been observed with a mean progesterone value of 40.7 nmol/l (12.8 ng/ml), 95% confidence limits of 28 to 53 nmol/l (8.8 to 16.7 ng/ml), and a range of 27 to 53 nmol/l (8.5 to 16.7 ng/ml), which extended significantly above as well as below the conception range, indicating that there is an optimal range for fertility with both an upper and a lower limit. The lower limit is of greater practical importance; and, partly to allow for assay variation, we suggest it should be taken as 30 nmol/l (9.4 ng/ml). It provided a clinically reliable criterion of potential fertility ("ovulation") in related studies. Our findings in treated conception cycles suggest that a higher value may be needed after treatment with clomiphene or gonadotropins because of the contribution from other stimulated follicles.