Incorrect hormonal interaction Premature menopauseOvulation problems
(jointly) account for 30% of infertility. This type of problem usually arises from 'mistakes' in the woman' hormonal interaction. As a result, the egg ripening process is not initiated, or is incomplete.
- If no ovulation occurs, it is called anovulation. In this case, no menstruation will take place either (amenorrhea).
- If there is a regularity problem with ovulation, it is called dysovulation. You may have irregular menstruation (oligomenorrhea), but your menstrual cycle may also be normal.
- Amenorrhea can also be caused by a premature exhaustion of the supply of eggs: this is known as premature menopause.
Incorrect hormonal interaction
The normal process of egg ripening and ovulation is the result of a finely tuned interaction between the brain and the reproductive organs:
- the hypothalamus excretes the hormone GnRH with clockwork regularity (every 60-90 minutes) depending on the stage of the menstrual cycle,
- this stimulates the hypophysis to produce the sex hormones FSH and LH (slower or faster),
- they stimulate the ovaries to start the ripening process of follicles (tiny fluid filled sacs, each containing an egg, and
- during this ripening process, the follicles begin producing oestrogen through a transformation of testosterone in the surrounding cells.
How do you know if you have PCOS?
If you have at least two of the three following symptoms, you are probably suffering from PCOS:
- ovaries with a large number of fluid filled sacs (follicles),
- a menstrual cycle in excess of 35 days,
- an increased concentration of male hormone in your blood, or signs that point to this: acne, loss of hair (on your head), excess body hair.
Polycystic Ovarian Syndrome (PCOS)
PCOS is the most common cause of ovulation problems in women of fertile age. Almost ten percent of all women have this syndrome, and one third of them (in part because of this syndrome) seek the help of reproductive medicine to have children.
PCOS is characterised by a large number of follicular fluid filled sacs in the ovaries. These small follicles are sometimes wrongly called cysts, hence the term 'polycystic’.
It is a heterogeneous disorder, the cause of which is not yet fully understood. We do know it involves an important genetic background.
- Usually women with a polycystic structure of the ovaries have a bad hormone interaction, often as a result of an increased concentration of LH (the ripening hormone).
- Often we also see an increased production of male hormones (androgens) and a reduced sensitivity for insulin (hyperinsulinism):
Paying attention to healthy food and physical exercise is extra important for women with PCOS.
- the first can result in acne and excess body hair,
- the latter in an increased risk of diabetes, particularly if the person is overweight.
PCOS can interrupt the normal progress of the menstrual cycle, causing less or sometimes no ovulations to occur. A spontaneous pregnancy becomes difficult to impossible.
Women who find themselves in this situation have various options if they want to get pregnant:
- controlled ovulation by administering hormones - see ovulation induction,
- in-vitro maturation of eggs - see IVM, and even
- hormonal stimulation followed by IVF/ICSI.
And finally we want to mention that sometimes PCOS can be treated with an operation involving ‘drilling’. With a laser or another source of heat, holes are drilled in the ovary, causing part of it to shrivel. This allows the hormonal balance to (temporarily) restore itself.
Disturbance in the brain
in the hypothalamus
- If the hypothalamus fails to produce sufficient levels of GnRH hormone, there is no or an incomplete ripening process, resulting in anovulation.
This rare condition can be treated by means of a GnRH-pump.
- Stress and drastic or uncontrolled weight loss can also lead to disturbances in the production of GnRH, also resulting in an irregular or incomplete ripening process.
Relaxation methods or controlled weight loss can rectify this.
If that is not effective, hormonal clomiphene citrate or gonadotrophine treatment or a GnRH-pump may be required (see ovulation-induction).
in the hypophysis
Sometimes, the hormonal disturbance is the result of too much prolactine in the blood. Prolactine is produced in the hypophysis. High levels can lead to interference in the follicle ripening process and thus anovulation or dysovulation.
- Quite often, an 'adenoma' or benign tumour in the tissue of the hypophysis is to blame. If it is a small tumour (a micro-adenoma, sometimes visible on a brain scan), it can be treated with medication.
- In the rare case that it is a macro-adenoma (larger, visible also on an x-ray), surgery will be required to remove it.
between the hypothalamus and the hypophysis
Sometimes, blood tests reveal all hormonal levels to be normal, apart from progesterone, which would cause problems related to ovulation. This would indicate a disturbance in the interaction between the hypothalamus en hypophysis: something not right with the frequency and regularity of GnRH release, with unsynchronised production of FSH an LH as a result. This either leads to disturbances of follicle ripening, or in rarer cases, a failure of LH levels to peak, resulting in no ovulation.
In cases where the follicle ripening process is affected, (detectable with ultrasound scan) the treatment of choice is to administer clomiphene citrate or gonadotrophins, often combined with hCG injections at the end of the ripening process.
The scientific term for this is 'Premature ovarian insufficiency' or POI and it indicates precisely what is wrong: the supply of primordial follicles (the follicles from which eggs ripen when prompted by the sex hormones) in the ovaries is prematurely exhausted. You have no periods anymore and frequently suffer hot flushes.
Unfortunately, the condition itself is not reversible: the only chance of pregnancy is with donated eggs (egg donation
) or adoption.