04:53 12th April 2013 | Ovulatory Abnormalities
Treating Ovulatory Abnormalities
The treatment of ovulatory problems is guided by the woman’s desire to get pregnant. Some women may only be desirous of seeing their periods while the majority of women are primarily interested in getting pregnant immediately or at least in their ability to conceive in near future. It is important to understand the underlining condition that is responsible for the ovulatory abnormality with detailed history, physical examination and necessary investigations.
Women not Seeking a Pregnancy
For those who are not seeking a pregnancy treatment is largely medical and starts with appropriate counselling, which may be limited to reassurance, especially in young women who have just started seeing their periods (menarche). Life style modification to achieve weight reduction in over weight patients is beneficial as regular ovulation may be restored following a reduction of as much as 10% of the body weight. Women with nutritional disorders like anorexia and bulimia will require highly professional counselling from a psychiatrist and reduction in strenuous exercise and accumulation of critical body fat may restore ovulation. The use of combined oral contraceptives pills containing both oestrogen and progesterone at a dosage recommended by a gynaecologist may be beneficial in women who are not ready for pregnancy. It is believed that the pills act by resetting the hypothalamic-pituitary-ovarian axis to induce regular ovulation and the monthly periods.
Women Seeking a Pregnancy
For those women whose main objective is to get pregnant; treatment protocols are more tailored towards achieving that purpose and may vary from ovulation induction, to treatment with in-vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) with or without the use of donated eggs depending on the woman’s ovarian reserves. Drugs like clomiphene citrate (Clomid) and follicle stimulating hormone are used to induce ovulation with the intention of achieving pregnancy. They can be used singly or in combination and are often administered with other management options such as are timed intercourse or with intrauterine insemination in order to achieve pregnancy. Other drugs like Letrozole (Femara) and other aromatase inhibitors are increasingly prescribed by fertility doctors for ovulation induction as they have fewer side effects than clomiphene and there are reduced chances of multiple pregnancies with them. It must be emphasized that women who do not conceive after six months of ovulation induction therapy may require IVF. Metformin is a useful adjuvant drug used to treat overweight women who have PCOS while bromocriptine (Parlodel) and cabergoline (Dostinex) have been used successfully to restore ovulation in conditions where there is excessive prolactin secretion. L-thyroxine (Euthyrox) should be used to treat hypothyroidism which will improve metabolism and ovulation may be restored.
The role of surgery in the management of ovulatory abnormalities includes laparoscopic removal of endometriotic cysts in the ovaries and occasionally laparoscopic ovarian diathermy in cases of women with PCOS which is refractory to clomiphene.
Intrauterine insemination with ovulation induction has found some usefulness in the management of infertility due to ovulatory disorders although its effectiveness still remains highly debatable. It is a simple, non-invasive and relatively inexpensive procedure which shows some benefits following about 3 or more cycles where other factors such as tubal patency and semen parameters are essentially normal.
IVF with or without ICSI remains the most effective treatment of infertility associated with ovulatory disorder especially when the ovulatory disorder coexists with other causes of infertility such as low sperm count. The prescribed course of treatment will depend on the woman’s medical history, findings on examination and the objective assessment of her ovarian reserves with hormonal assessments. These define the choice of treatment with her eggs or with donated eggs from a younger woman with a higher fertility potential who may be known to the couple or may be totally anonymous.
The management of an ovum donor cycle should not be taken with levity but should be handled within the formal structures of a reputable fertility clinic which assures the patients of their safety, the safety of their unborn child and the safety of the donor. The couple and the donor must be adequately counseled before and during treatment with IVF to make sure that they are all committed to the decision which has been made and ensure that the donor has not been coerced.
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