Ask the Doctor: 10 Questions About Ovulatory Disorders

We asked Dr. Asima Ahmad the top 10 questions she hears about ovulation and ovulatory disorders:

What defines an ovulatory disorder?
An ovulatory disorder is present when an egg is not being released from the ovary on a regular, monthly, basis.

What can cause ovulation to stop?
Ovulation can stop due to a variety of reasons, the most common reasons being hormonal. Imbalances or changes in hormone can affect your menstrual cycle. These hormones can be those from the brain, such as follicle stimulating hormone (FSH), luteinizing hormone (LH), thyroid stimulating hormone (TSH) or prolactin (PRL). Polycystic Ovary Syndrome, commonly known as PCOS, is also a common cause of oligo-ovulation (ovulating infrequently) or anovulation (not ovulating). As many as 5-20% of women may be affected. Too much or too little weight can also throw hormones off and impede ovulation - it’s best to strive for a body mass index in the normal range of 18-25.

What female hormones become imbalanced?
There are numerous endocrine hormones are involved with ovulation:

  • Follicle stimulating hormone, known as FSH, stimulates egg maturation and ovarian follicular growth, and thus increasing estradiol (a form of estrogen) production. When estradiol levels rise, FSH decreases. A normal FSH level at the start of the menstrual cycle is <10. In a female with anovulation, extremely low levels can possibly indicate a condition called functional hypothalamic amenorrhea (FHA) and extremely high levels can possibly indicate premature ovarian insufficiency (POI) in a younger female (<40yo) or menopause in an older female.
  • Luteinizing hormone, known as LH, is the hormone that spikes just prior to ovulation. When you take an ovulation prediction test, it is measuring the amount of LH in the body and looking for a higher LH. An extremely low LH in conjunction with an extremely low FSH in a female with anovulation supports the diagnosis of FHA. Also, without the LH spike in a menstrual cycle, and without the help of medications, a female would not ovulate.
  • Estradiol, known as E2, is a form of estrogen made by the ovaries. Estradiol is secreted by a growing follicle – the fluid-filled sac that surrounds a maturing egg.
  • Progesterone is produced by the corpus luteum, the cyst that forms from the follicle that a woman has ovulation from, after ovulation occurs. This progesterone supports early pregnancy until the placenta takes over.

How common are ovulatory disorders?
Ovulation issues are a leading cause of infertility in women. The good news is that treatment for ovulation disorders, depending on the cause, can be successful.

Does taking birth control for years cause issues with ovulation?
Taking oral contraceptive pills (OCPs) does not cause long-term issues with reproduction. There are myths that say after someone comes off OCPs, there is a delay to ovulation or menstruation. This is not true. You can get pregnant your first cycle after coming off OCPs. What we do see, however, is that when women are on OCPs for an extended period of time, this may mask a issue and coming off the pills unmasks it.

If I don’t get my period, am I still ovulating?
It is possible to ovulate without a period in some scenarios (i.e. having a progestin IUD) but without a period to signal the next cycle, it is impossible to estimate when you are ovulating without regular testing. You can use ovulation prediction kits to gauge when ovulation is happening, though most find this method to quickly become very frustrating. If you have stopped taking OCPs or another form of birth control and still haven’t had a period after three months, it’s best to see a physician for an evaluation.

What medication is used to start ovulation?
Medications to spur ovulation can come in the form of a pill or an injectable medication, depending on the treatment regimen. Two oral medications, commonly used for ovulation induction, are clomiphene citrate (a selective estrogen receptor modulator) and letrozole (an aromatase inhibitor). Both, by different means, increase the release the FSH from the brain, thus resulting in follicular development and egg maturation. There are also injections that are formulations of FSH that one can take. To stimulate the process of ovulation, one can also mimic the LH surge by taking a hCG subcutaneous injection. Nearly all patients are nervous about doing injections, which involves a small needle going into the fat of the belly, but it is nothing more than a small prick that most adjust to quickly.

Can I do anything to restart ovulation naturally?
There are several factors that can impact ovulation such as diet, exercise, weight, and stress. Eat a diet rich in vegetables, fruits, healthy fats, organic meats and whole grains. Exercise, combining a mixture of aerobic with low-impact exercise such as yoga, barre, swimming and walking can help manage weight and stress. Excessive exercise can cause ovulation to stop – due to FHA. Working towards a healthy body mass index (BMI) can improve fertility. In overweight patients, losing as little as 5-10% of weight can have a big impact and underweight patients are encouraged to gain weight to reach a normal BMI. Managing stress through meditation, mindfulness, deep belly breathing, acupuncture, massage or whatever relaxes you can also help calm the body and mind.

What treatment does an ovulatory disorder require?
Treatment will vary depending on the specific patient evaluation and cause of an ovulatory disorder. Common first steps are to restart ovulation through medication and make the positive health changes listed above that can encourage ovulation. Sometimes, this is enough to start ovulation again and conception can happen through timed intercourse. Other options include an intrauterine insemination with the next step being in vitro fertilization. We advise starting small and progressing to more aggressive treatment options if necessary.

How is an ovulatory disorder diagnosed?
A diagnosis is determined after a review of a patient’s medical history, a physical examination, a laboratory evaluation and imaging such as an ultrasound. Blood tests that measure the levels of key hormones including FSH, LH, E2 and progesterone are essential when evaluating ovulatory potential. A transvaginal ultrasound can also evaluate the ovarian function and the presence of follicles and cysts in the ovaries and well as the uterine lining.