Anovulatory Infertility

An anovulatory cycle is a menstrual cycle in which ovulation is absent.  Anovulation is a common cause of infertility among females.  It tends to ooccur commonly during adolescents and in the perimenopausal stage (years before menopause), although it may occur anytime during the childbearing years.

Epidemiology

Among infertile women, problems with ovulation may occur in up to 40% of women.

Pathophysiology

During anovulatory cycles, a woman would not be able to conceive because there is no egg cell to be fertilized by the sperm.  Women who have anovulatory cycles also tend to have irregular cycles, which lessen her chances to become pregnant because ovulation tends to be less frequent.  These women may also have hormonal irregularities, resulting to other problems, such as very thin or over thickening of the lining of the uterus where the fertilized egg needs to implant, very low progesterone levels, and lack of fertile cervical mucus. 

Causes

Anovulation can result from several causes, from lifestyle problems (eg, diet, excessive stress) to hormonal problems due to abnormal function of organs. 

The most common cause of anovulatory cycles is hormonal imbalance.  Severe anxiety, obesity, prolonged and strenuous exercise programs, and eating disorders may affect the output of hormones released by the hypothalamus in the brain by suppressing it.  Other causes may be conditions like hyperprolactinemia, hypothalamic dysfunction, polycystic ovary syndrome, or tumors of the ovaries, pituitary, and adrenal glands.  Prolonged use of oral contraceptive pills (OCPs) and injectable steroid contraceptives (ie, Depo-Provera) can disrupt the normal hypothalamus-pituitary-ovarian pathway, thus suppressing ovulation.

Clinical Features

Women with anovulatory cycles tend to have irregular periods.  Cycles may be longer than 36 days, shorter than 21 days, or the length of the cycles varies.  Some women sometimes fail to have their periods altogether. 

Diagnosis

Problems with ovulation can be difficult to detect, but most are alerted by their symptoms.  Hormone levels may be checked, including progesterone, luteinizing hormone (LH), follicle stimulating hormone (FSH), and prolactin.  Ultrasound may confirm the presence of polycystic ovaries and to track follicle development and ovulation.  Other tests include CT scan or MRI of the pituitary and hypothalamus to exclude a tumor and endometrial biopsy.

Treatment

Treatment for anovulation would depend on the underlying cause.  Changes in lifestyle may result in the resolution of the condition, like weight gain, weight loss, lessening the exercise routine, and stress reduction.  The most common medical treatment is the use of fertility drugs.  Clomiphene citrate is often the first drug given, which can trigger ovulation in about 80% of affected women and help them conceive within six months.  Other treatments can be medications for specific conditions and surgery for tumors.

Efficacy of Alternative and Mental Health Treatments According to GRADE* Ranking:

Qigong:

Recommendation: no recommendation (there is insufficient evidence to show that Qigong can help treat infertility)

Grade of Evidence: very low quality of evidence

* www.gradeworkinggroup.org