Ovulatory Dysfunction

O vulatory Dysfunction is irregular, abnormal, or absent ovulation.  The most common symptom noted in women with ovulatory dysfunction is irregular or absent menstrual cycles.  A common cause of infertility, ovulatory dysfunction accounts for about 40 percent of female infertility cases.  Fortunately, your doctor can often correct the issue once the source of irregular ovulation has been identified.   

In a menstrual cycle where ovulation occurs on a regular basis, the average length of the cycle is anywhere from 21-35 days.  There are also other symptoms associated with the onset of menses including mild lower abdominal bloating and cramps, breast tenderness, and moodiness.  Women with ovulatory dysfunction typically have cycles that are shorter than 21 days or longer than 35 days. Often, the length of their cycles varies greatly from one month to the next, and many report none of the common symptoms of an impending menstrual cycle.  

Ovulatory dysfunction can occur for various reasons including (but not limited to) Polycystic Ovarian Syndrome (PCOS), obesity, low body weight and low body fat, anorexia nervosa, excessive exercise, premature ovarian failure, decreased ovarian reserve,  thyroid dysfunction, pituitary dysfunction, and extreme stress. Usually, the symptoms will dictate which lab tests and procedures your doctor will order during the evaluation.  These may include lab work to assess hormone levels and an ultrasound to assess the uterus and the ovaries, which can help identify the cause of the ovulatory dysfunction.

Diminished Ovarian Reserve

Diminished ovarian reserve is a term that is used when the ovary does not contain as many eggs, or oocytes, as expected at a given age. As a woman gets older, the ovarian reserve, or egg supply, gradually decreases.  A woman is born with all the oocytes that she will ever have, and only about 400 oocytes are released during the reproductive years of a woman’s life.  

Although we expect the ovary to age in a specific way, the rate at which oocytes are lost is not something that can be controlled and varies among individuals, but a woman’s genetic makeup does influence the outcome.  One-third of couples in which the female partner is thirty-five years or older will have difficulty conceiving.  Ovarian Reserve screening is an essential tool in the initial evaluation of patients experiencing infertility, especially those who are over thirty-five.  

Several measures exist for testing a woman’s ovarian reserve.  Your doctor may order a Cycle Day Three lab to evaluate the serum FSH (Follicle Stimulating Hormone) and Estradiol levels. These hormones can predict ovarian reserves when tested together on day three of a woman’s menstrual cycle.  Estradiol should be less than 50 and FSH should be less than 10 to be considered within normal limits.  If the FSH and/or Estradiol are elevated, these results could indicate decreased ovarian reserve.  

Another way to evaluate ovarian reserve is to do a basal antral follicle count within the first few days of the menstrual cycle.  For this test, an ultrasound is performed, allowing the physician to determine the number of follicles (which contain the oocytes) the patient has present at the beginning of the cycle. If a woman has at least eight follicles present at this ultrasound, doctors anticipate that she will have normal ovarian reserve.  

Although ovarian reserve testing gives a physician insight into the quantity and quality of oocytes remaining, age seems to be the most valuable predictor of oocyte quality. Ovarian Reserve testing helps guide doctors toward the best treatment for their patients. Diminished ovarian reserve does not mean that a couple will not achieve a successful outcome, but patients may require more intense treatment options to achieve their dreams of parenthood.

Premature Ovarian Failure (POF)

Premature ovarian failure (POF) is the loss of normal ovarian function before the age of 40. At the beginning of a woman’s menstrual cycle, the pituitary gland secretes FSH, which causes the follicles to begin to mature and produce estrogen.  The rising estrogen levels give the pituitary gland the signal that FSH is no longer needed at this time.  If follicle maturation does not occur, a woman does not release ample quantities of estrogen, which causes the follicle stimulating hormone to continue to increase.  This is typically why a woman with POF has higher levels of FSH on evaluation.

Common symptoms noted with POF include absence of a menstrual cycle or irregular menstrual cycles, hot flashes or night sweats, vaginal dryness, decreased sexual desire, difficulty concentrating, and irritability.

Although it seems that POF is familial and a genetically predetermined condition, a few other factors can increase the risk of POF. The most obvious being age, as discussed previously.  Chromosomal defects can also contribute to the onset of POF such as Turner’s syndrome (where a woman has only one X chromosome instead of the two X chromosomes) and Fragile-X syndrome. Exposure to toxins can induce ovarian failure as well.  The most common causes of toxin-related ovarian failure are due to women who have had radiation or chemotherapy as these treatments can damage the genetic material in the oocyte.  Environmental toxins such as cigarette smoke, chemicals and pesticides may also accelerate ovarian failure.

Infertility is commonly associated with POF.  Although doctors don’t have a treatment to improve fertility in patients with this condition, IVF with donor eggs is a viable option for many couples trying to achieve a pregnancy.

Women with POF may develop osteoporosis due to the lack of estrogen.  Replacing this estrogen can help prevent osteoporosis and relieve many of the symptoms that arise from estrogen deficiency such as hot flashes, mood changes, and vaginal dryness. Your doctor may also suggest progesterone as well as estrogen to prevent the lining of the uterus from developing precancerous changes. When a woman is on long-term estrogen therapy, issues arise about the association with breast cancer and cardiovascular health.  In a young woman with POF, the benefits of hormone replacement usually outweigh the risks.

A diagnosis of premature ovarian failure can bring mixed emotions to a woman who has dreamed of having a child with her genetic makeup.  Providing support and guidance during this time will ensure that the individual’s needs are adequately met.