Dr. Kemi Ailoje

This week we will conclude the management of anovulation using various treatment methods.

Hyperprolactinemia (High prolactin levels): High levels of the hormone called prolactin, which is secreted by the pituitary gland, can suppress ovulation. This can be due to the presence of a pituitary tumor called a microadenoma. It is safely and easily treated with a drug called bromocriptine, starting from a dosage of 1.25 mg and slowly increased to 2.5 mg over a month or so. Once the prolactin level falls below 1000 IU/L ovarian cycles normalize and ovulation is restored in 70-80% of women. Other drugs used in this condition include; cabergoline and quinagolide, which have a longer duration of action and less severe side effects than bromocriptine.

Hypothyroidism: In many women with anovulation the thyroid is underactive. The body responds to this by secreting Thyrotropin Stimulating Hormone (TSH) to stimulate thyroid hormone secretion, but this in turn stimulates prolactin production as well. This results in suppression of ovulation. Thus, any patient with high prolactin levels should be checked for primary hypothyroidism and treated with appropriate doses of thyroid hormone.

Weight disorders: In managing anovulation, weight is a very important factor has a patient should not be underweight (body mass index below 20) or overweight (body mass index above 30). A body mass index of about 20-29 should be achieved before any treatment or management plan commences.

Treatment of Weight Disorders

Anovulation is most often due to polycystic ovarian syndrome (PCOS), in which the ovary is thickened and contains multiple cysts, androgen effects are visible in the woman’s body, and insulin resistance is present. PCOS is frequently, but not always, associated with infertility. Such women are quite often obese or overweight (body mass index above 30), and this contributes to the insulin resistance. They should be advised to pursue weight loss, because if even 5% of body mass is reduced there is a significant improvement in insulin sensitivity, luteinizing hormone (LH) and free testosterone levels also decrease, both of which lead to regular menstrual cycle in many patients.

On the other hand, women who have eating disorders or are severely malnourished, with a body mass index below 20, may have to gain a certain amount of weight before they resume ovulatory cycles. The anovulation should not be separately treated until the body mass becomes at least low to normal.

Surgical Management: This is usually adopted to resolve the underlying cause for anovulation, typically when other therapies have failed in an individual. Ovarian drilling and ovarian wedge resection are other surgical management used in the treatment of anovulation due to PCOS.

 Surgical Treatment

Ovarian wedge resection was the first method of surgical treatment of PCOS but has now been replaced by ovarian drilling, with the aim of reducing the quantity of androgen-secreting tissue within the ovary. It is quite as successful as FSH injections are, but the risks of multiple pregnancy and OHSS are significantly lower. However, if too much of the ovarian tissues are destroyed the woman may suffer premature ovarian failure (early menopause). Again, if healing is complicated, it could lead to adhesion formation within the abdominal cavity.

Treatment options may involve consultations with different specialists such as:

Neurosurgeons – In the presence of a brain tumor (macro adenoma) that is unresponsive to medical management.

Psychiatrists/psychologists – For patients with eating disorder (anorexia, nervosa and bulimia)

Nutritionists- For patients struggling with the above eating disorders.

Gynecologic Oncologists/General Surgeons – In the case of either an ovarian cyst (adnexal mass) of benign (non-cancerous) or malignant (cancerous) origin.

Reproductive Endocrinologists and Infertility specialists – When fertility is desired in order to appropriately monitor ovulation induction in the management of PCOS.

Assisted Reproductive Technology (ART): Anovulation is a major cause of infertility in women and when every other option has failed, ART is another good and sure option as the success rate has increased over the years. In using ART, there has to be a management plan, donor eggs can be used for procedure as this would cover up for women who are patients of anovulation and thus cannot produce eggs at all or cannot produce eggs of good quality. Also, women that their endometrium has been affected and cannot allow the implantation of embryo, a gestational host (surrogate) can be used for them. ART gives room for various options like In Vitro Fertilization (IVF), Intra Cytoplasmic Sperm Injection (ICSI), Intra Morphological Sperm Injection (IMSI), Gamete Intra Fallopian Tube Transfer (GIFT), Zygote Intra Fallopian Tube Transfer (ZIFT), this makes parenthood possible for everyone regardless of what the cause of infertility is. Success rate of treatments is high in patients with anovulatory infertility. Management of this case and also which form of ART best suits a patient can easily be handled and determined by gynecologists and fertility specialists with the patient’s consent or approval.

*Note: Dear reader, part four was omitted. We hereby apologize for the error.