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Day 2: Reproductive Endocrinology and Infertility

What factors contribute to infertility?
Ovulatory disorders are one of the most common reasons why women are unable to conceive, and account for 30% of women's infertility.  Fortunately, approximately 70% of these cases can be successfully treated by the use of drugs. The causes of failed ovulation can be categorized as follows:

(1) Hormonal Problems 
These are the most common causes of anovulation.  The process of ovulation depends upon a complex balance of hormones and their interactions to be successful, and any disruption in this process can hinder ovulation.  There are three main sources causing this problem:

Failure to produce mature eggs
In approximately 50% of the cases of anovulation, the ovaries do not produce normal follicles inwhich the eggs can mature.  Ovulation is rare if the eggs are immature and the chance of fertilization becomes almost nonexistent.  Polycystic ovary syndrome, the most common disorder responsible for this problem, includes symptoms such as amenorrhoea, hirsutism, anovulation and infertility.  This syndrome is characterized by a reduced production of FSH, and normal or increased levels of LH, oestrogen and testosterone.  The current hypothesis is that the suppression of FSH associated with this condition causes only partial development of ovarian follicles, and follicular cysts can be detected in an ultrasound scan.  The affected ovary often becomes surrounded with a smooth white capsule and is double its normal size.  The increased level of oestrogen raises the risk of breast cancer.
 
Malfunction of the hypothalamus
The hypothalamus is the portion of the brain responsible for sending signals to the pituitary gland, which, in turn, sends hormonal stimuli to the ovaries in the form of FSH and LH to initiate egg maturation.  If the hypothalamus fails to trigger and control this process, immature eggs will result.  This is the cause of ovarian failure in 20% of cases.
 
Malfunction of the pituitary gland
The pituitary's responsibility lies in producing and secreting FSH and LH.  The ovaries will be unable to ovulate properly if either too much or too little of these substances is produced.  This can occur due to physical injury, a tumor or if there is a chemical imbalance in the pituitary.
 
(2) Scarred Ovaries
Physical damage to the ovaries may result in failed ovulation. For example, extensive, invasive, or multiple surgeries, for repeated ovarian cysts may cause the capsule of the ovary to become damaged or scarred, such that follicles cannot mature properly and ovulation does not occur.  Infection may also have this impact.

(3) Premature Menopause
This presents a rare and as of yet unexplainable cause of anovulation.  Some women cease menstruation and begin menopause before normal age.  It is hypothesized that their natural supply of eggs has been depleted or that the majority of  cases occur in extremely athletic women with a long history of low body weight and extensive exercise.  There is also a genetic possibility for this condition.

(4) Follicle Problems
Although currently unexplained, "unruptured follicle syndrome" occurs in women who produce a normal follicle, with an egg inside of it, every month yet the follicle fails to rupture.  The egg, therefore, remains inside the ovary and proper ovulation does not occur.

How long should a woman try to conveive before consulting a infertility specialists
 
If you're under 35 and have had frequent (about two or three times a week) unprotected sex for at least a year without conceiving (or three to six months if you're 35 or older), you may want to consult a fertility expert.

Also, if any of the following conditions or activities apply to you, or if you smoke, take medications such as some steroids or antidepressants, or are more than 25 percent over- or underweight, tell your doctor. Waiting a full six months or a year to try to conceive naturally may be a waste of valuable time as your biological clock continues to tick.

See a doctor if you have a history of:

• Pelvic inflammatory disease
• Fibroids
• Endometriosis
• Sexually transmitted infection such as chlamydia or gonorrhea
• Irregular periods
• Surgery on your reproductive organs or intestines
• DES (a drug used between 1941 and 1971 to prevent miscarriages) use by your mother when she was pregnant with you
• Chronic illness such as diabetes, cancer, thyroid disease, asthma, or depression



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Manvinder Singh, M.D.
DMC Hutzel Women's Hospital 

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