Ovulation refers to the process of releasing 1 egg each month, which happens about 2 weeks prior to the start of a period. Many women have irregular or non-existent menstrual cycles where the egg is not regularly released each month. Others may release an egg but do not have the normal hormonal balance to maintain development of an embryo.
Testing: Hormone testing, transvaginal ultrasound.
Treatment: Depending on the cause, different medications may be used for ovulation induction.
Polycystic Ovarian Syndrome (PCOS)
PCOS is a complex hormonal disorder that is the most common cause of irregular menstrual cycles and anovulation. Other associated symptoms include acne, oily skin, and excessive hair growth (hirsutism). Obesity and pre-diabetic signs are also seen in some women with PCOS. Ovaries of women with PCOS usually have a distinctive appearance on ultrasound.
Testing: Hormone testing, transvaginal ultrasound.
Treatment: Diet modification, exercise, and weight loss may eventually restore regular menstrual cycles and ovulation. Occasionally, metformin, a drug that is used to treat diabetes, can also help women with PCOS. The most common medications used to induce ovulation are Clomiphene citrate and Letrozole. Gonadotropins can be another alternative.
Age is the most common reason for infertility. Women are most fertile in their 20’s and early 30’s. After 35, the rate of infertility rises quickly. By the age of 40, 50% of women are infertile, and by the age of 45, the rate is >95%.
Testing: Ovarian reserve testing (Day 3 FSH & estradiol, AMH, antral follicle count). There is no test for egg quality.
Treatment: Superovulation, IVF, egg donor IVF.
Fallopian tube blockage
Tubal blockage, where the fallopian tubes are blocked or damaged, is a common cause of infertility. Without patent and functioning Fallopian tubes, the sperm and the egg cannot meet and natural pregnancy cannot occur.
Testing: Hysterosalpingogram, possible laparoscopy.
Treatment: Laparoscopy (surgery) or IVF.
The thyroid gland is located in the neck and produces hormones that are important for many metabolic functions throughout the body, including reproduction. Hyper- or hypothyroidism refers to over or under activity of the thyroid gland. These two conditions can cause infertility by disturbing normal ovulation or increasing the risk for miscarriages.
Testing: Blood test (TSH, free T4, and T3)
Treatment: Hypothyroidism: Medication-synthetic thyroid hormone.
Hyperthyroidism – Referral to a medical endocrinologist for further testing and treatment.
Prolactin is a hormone that is secreted from the pituitary gland in the brain and is normally elevated during pregnancy and breast feeding. However, in some women, high levels are found even when not lactating or pregnant, which can interfere with ovulation and implantation. When levels are very high, women may notice a milky discharge from the breasts. Most of the time the reason for the high prolactin levels is undetermined, but occasionally a small overgrowth on the pituitary gland called an adenoma may be responsible.
Testing: Blood test for prolactin; occasionally an MRI of the pituitary may be ordered.
Treatment: Medication -usually Cabergoline, Bromocriptine).
Endometriosis is a fairly common condition that affects up to 10% of women. It is associated with pelvic pain and infertility. Pain is usually worse around the time of the menstrual period, and a sensation of deep pain may also be significant during intercourse. Infertility is usually caused by inflammation and scar tissue created by endometriosis around the Fallopian tubes and ovaries.
Testing: Diagnosis can only be made with laparoscopy. Transvaginal ultrasound may be helpful.
Treatment: For the treatment of infertility associated with endometriosis, IVF is generally the most successful treatment. However, laparoscopy and less aggressive treatments can be considered in milder cases. For pain associated with endometriosis, various medical treatments are also available, although most will not address infertility.
The uterus can be affected by several problems that can prevent implantation of the embryo and increase the risk of miscarriage. Some of these problems can be congenital (anomalies of the structure or shape), while others can develop over time (polyps, fibroids, scar tissue, etc.). While these problems may be visible with various diagnostic tests, they may have no effect whatsoever on fertility.
Testing: Transvaginal ultrasound, hysterosalpingogram, and/or hysteroscopy.
Treatment: Surgery (usually hysteroscopy +/- laparoscopy), although not all problems can be fixed surgically.
Primary Ovarian Insufficiency (POI)
The average age of menopause is 50-51, but about 10% of women under the age of 40, and 1% under the age of 30 will go through early menopause. Women with POI experience a faster loss of eggs than is expected for their age. Occasionally, POI may be associated with other autoimmune diseases or previous chemotherapy treatments for cancer.
Testing: Blood tests (day 3 FSH/estradiol, AMH, genetics and other tests), transvaginal ultrasound.
Treatment: Premature menopause cannot be reversed, and most women with POI are unfortunately poor candidates for treatments with their own eggs such as IVF. Egg donation, however, offers a high probability of pregnancy. That said, 5-10% of women who appear to be in early menopause will conceive naturally.