Absence of ovulation

Menstrual cycles caused by ovarian activity (or ovarian cycles) not accompanied by ovulation. The serum progesterone stays low, whereas some development of tertiary follicles and production of estradiol takes place. See also anovulatory dysfunctional uterine bleeding.

Irregular and generally heavy bleeding caused by anovulatory cycles. The underlying causes and how to prevent the sometimes harmful consequences, including endometrial hyperplasia.

Absence of ovulation caused by insufficient GnRH drive from the hypothalamus, so that the pituitary gland doesn't produce enough follicle stimulating hormone. Usually accompanied by absent periods (amenorrhea).

Natural process by which a mature follicle in the ovary opens to release the secondary oocyte, or egg, enclosed in a sticky blob of mucus-like material, the cumulus mass.

The use of drugs to stimulate the development of follicles in the ovaries to undergo ovulation, such as clomiphene, various preparations containing follicle stimulating hormone (FSH), and human chorionic gonadotropin (hCG). The two main situations for it are: in the treatment of infertility due to anovulation typically when there is oligomenorrhea or amenorrhea; and for superovulation in assisted conception (e.g. in vitro fertilisation and gamete intrafallopian transfer)

A mild pain that precedes ovulation by about 12 hours, felt in the left or right side, but not by everyone or in every ovarian cycle. A good indication of ovulation if it is felt. Can be exaggerated in endometriosis and in so-called pelvic congestion. The time from ovulation pain until the onset of menstruation (ignoring for this purpose any premenstrual spotting) is a good measure of the length of the luteal phase. Should not be treated with NSAIDs such as Advil or Nurofen if you are trying to get pregnant, because these analgesics have been linked to the so-called luteinised unruptured follicle syndrome, or LUF.

Heavy but generally regular bleeding caused either by pathology in the uterus, such as fibroids, or by a generalised bleeding disorder, such as thrombocytopenia (a low platelet count), von Willebrand's disease (can run in families), or treatment with anticoagulant drugs. The formal term for it is menorrhagia.

Immediately prior to ovulation.

A large, mature tertiary follicle that will respond to an adequate LH surge or injection of human chorionic gonadotropin (hCG) by undergoing ovulation, releasing its egg. Produces estradiol and, with exposure to LH or hCG, progesterone.

Intentional induction of multiple ovulations at once, using injections of follicle stimulating hormone and human chorionic gonadotropin, for assisted conception. Inevitably there is a risk of multiple pregnancy unless egg retrieval is performed.

Scar tissue, in particular between the serosa (surface lining) of abdominal or pelvic organs in the peritoneal cavity, which can interfere with the access the fallopian tube has to the ovary at ovulation. Adhesions can be thin and transparent (sometimes called filmy or Grade 1), a little like thin plastic wrap; thicker, and containing more scar tissue and blood vessels (Grade 2); or thick, dense and tough (Grade 3). Adhesions are caused by infections, endometriosis or a previous operation. Not all adhesions are important: it depends on where they are. See also intrauterine adhesions. The treatment of adhesions requires microsurgery, and there are special steps that have to be taken to stop them coming back again.

Absent menstrual periods, either because of absent ovulation (anovulation) or because of absence of, destruction of, or obstruction to the menstrual flow from the uterus, such as with intrauterine adhesions (when it's known as Asherman's syndrome).

"Anorexia" means a profound loss of appetite, followed by loss of weight; "nervosa" means that there is a nervous or mental basis for the state, in this case a belief by the person affected, and contrary to the perception of others, that she (very rarely he) is overweight. She stops eating, may induce vomiting, and uses laxatives to keep the intestines empty and the stomach flat. The menstrual periods stop (there is amenorrhea for two reasons: the weight loss and the underlying mental disturbance, both of which cause hypothalamic anovulation. Medical complications from induced vomiting and laxative abuse can be serious, occasionally fatal. Treatment, which includes psychological and psychiatric counseling, is difficult and is not always completely accomplished. It's a condition chiefly of adolescent girls; the younger the patient the better the chance of cure. For fertility, ovulation induction as often required.

A fluid-filled space between the follicle cells, the development of which marks the transformation of a tertiary follicle from a secondary follicle. Composes the bulk of the mature, preovulatory follicle (sometimes called the Graafian follicle) and very obvious on transvaginal ultrasound scanning during monitoring of follicular development as dark, "echolucent" spaces within the ovary.

A group of medical treatments ranging from assisted insemination (IUI) to in vitro fertilisation (IVF), including its technical variants (such as GIFT, ICSI and PGD, and with the following common characteristics: (1) they are aimed at increasing the chance of pregnancy each month, thus overcoming the medical disability of infertility; (2) there is little or no "spillover" of therapeutic effect beyond the cycle or month in which treatment is invoked; and (3) there is some form of procedural intervention, with sperm, eggs or embryos spending some time outside of the body. It's not necessary for there to be stimulation of the ovaries (superovulation) for multiple development of follicles.

An inexpensive way of detecting ovulation through the effect progesterone has on the hypothalamus, increasing the body's temperature a few tenths of a degree. Best recorded using a BBT thermometer (with a smaller scale than thermometers used to record fevers or high temperatures) first thing in the morning before rising, and preferably in the vagina for accuracy. Day 1 of the chart is the first morning when there is menstruation (a period). Commonly there's a dip in the temperature just before the sustained rise that indicates that ovulation has occurred (a "biphasic chart"). The chart typically records the days you are menstruating, when you have sex and when you're aware of mucus and ovulation pain. Best used to document: (1) the presence and length of the luteal phase, especially if clomiphene is being used for ovulation induction; and (2) the timing of symptoms such as premenstrual spotting. Not as good for predicting ovulation as LH-testing in urine.

(BMI) An estimate of the amount of fat a person has, calculated by dividing his or her weight (expressed in kilograms) by the square of the height (expressed in meters). Normally between about 20 and 25, although the upper limit is higher with age. A BMI below 20 generally causes oligomenorrhea, then amenorrhea, through anovulation.

Bleeding (usually irregular and light, i.e. 'spotting') while on the birth control pill (the oral contraceptive pill) or while taking a progestogen. With regard to the pill, it is common (and of no sinister importance) in the first few months of pill use; but if it happens after many months' satisfactory use of the pill then it can signal: (1) interference with the efficacy of the pill (i.e. a risk of ovulation and pregnancy) by an illness with diarrhea, simultaneously taking antibiotics, or a drug interaction (taking additional medications that speed up the pill's metabolism; or (2) coexisting pathology of the cervix or the uterus. Unexplained or persistent breakthrough bleeding means you should see your physician.

imilar to bromocriptine, but more potent and with fewer side effects; used once or twice weekly to lower production of prolactin in hyperprolactinemia. Not yet approved for infertility treatment, but no adverse fetal effects have been reported when used for ovulation induction.

Sticky secretion from the canal of the cervix, the job description of which is to keep sperm (spermatozoa) out unless ovulation is about to take place, when it becomes voluminous, watery, stretchable (Spinnbarkheit) and forms a crystalline ferning pattern when allowed to dry on a glass slide. Natural family planning clinics can teach you to look for it in the vagina -- useful for getting pregnant as well as for avoiding it.

A score (out of 12) for the quality of cervical mucus, gauged by scoring each of the following from 0 to 3: the cervix should be open and the volume of mucus should be good (although every woman will be different for both these parameters, they will be consistent in one woman from ovulation to ovulation); the mucus should be clear, watery and stretchy (Spinnbarkheit); and the mucus should produce a complete 'ferning' pattern when it's allowed to dry on a microscope slide. The first two criteria vary at ovulation in different women (so anything above a score of 9 or 10 can be normal), but the same woman should achieve the same Insler score from one ovulation to the next. Also called the Insler score.

A drug that blocks the action of estrogens and so tricks the pituitary gland into thinking the ovary's follicles are not producing enough estradiol, so that natural FSH production is temporarily increased, the ovaries thereby are stimulated, and follicles grow. The LH surge and ovulation usually follow naturally, but human chorionic gonadotropin can be given if monitoring is used to make sure the follicle is properly mature. Brand names: Clomid (Marion Merrell) and Serophene (Serono)

Latin for yellow body, the description being that of the solid or cystic structure in the ovary after ovulation. Derived from the ovulating Graafian follicle. At first red and friable as arteries and veins invade the collapsed follicle, it soon matures into a gland that is very efficient at producing progesterone, a hormone that's soluble in the fat and which therefore gives the corpus luteum its yellow color. Provides its name to the second, or luteal phase of the ovarian cycle, as well as to luteinising hormone, which causes the corpus luteum to be formed and sustains it until, in the event of pregnancy, it is supported instead by human chorionic gonadotropin. The appearance of the corpus luteum on transvaginal ultrasound is so variable (and so able to be confused with a serious abnormality of the ovary) that for accurate diagnosis of such pathology it is best to scan in the follicular phase or while taking a progestogen to prevent formation of this structure. Plural: corpora lutea.

A collection of specialised granulosa cells, surrounding the ovulating egg (or secondary oocyte) in a sticky, mucus-like matrix. Sticks to the fallopian tube's fimbrial end after ovulation by a specific interaction with the tube's cilia.

The natural process in which the older the female fetus, girl or woman gets the fewer are the eggs (as primordial follicles) left in the ovaries; the huge majority of eggs are lost because of atresia, only a tiny fraction by ovulation. Before the eggs are depleted there is a mild or moderate elevation in serum FSH when measured during the menstrual phase (often called a day 3 FSH. When the eggs are more or less depleted there will be primary ovarian failure and, in women who have had periods, the menopause will take place, perhaps prematurely (premature menopause). Infertility, however, usually precedes total egg depletion by up to 10 years. See also mitochondrion and oopause.

The preovulatory follicle, or Graafian follicle, that has won the responsibility for producing estradiol for the rest of that particular ovarian cycle. Chosen by the end of the first week of the follicular phase. Its destruction (whether accidental or intentional) means that a new follicular phase must start, with ovulation two weeks later, whereas destruction of one of the tertiary follicles before one has become dominant causes no interference with the timing of ovulation for that cycle.

(DUB) Heavy bleeding from the uterus. See anovulatory dysfunctional bleeding (often painless and irregular) and ovulatory dysfunctional bleeding (usually regular and can be associated with dysmenorrhea).

Procedure for obtaining eggs (oocytes), involving the passing of a needle into a mature (or preovulatory follicle, either directly at laparoscopy or (more usually) via the vagina guided by transvaginal ultrasound.

Overgrowth of the endometrium, caused usually by prolonged action of estrogen unopposed by progesterone (i.e. prolonged anovulation), as is the case in, particularly, the polycystic ovary syndrome. Potentially dangerous, because it can turn to cancer of the endometrium. Can be suspected by an echogenic appearance of the endometrium on transvaginal ultrasound and is confirmed by pathological examination of tissue obtained at curettage.

A common condition in which tissue like the lining of the uterus (the endometrium), grows somewhere else, sometimes causing dysmenorrhea, premenstrual spotting, infertility, dyspareunia and ovulatory dysfunctional uterine bleeding.

Also "fimbriated end": the open, outside end of the fallopian tube in contact with the surface of the ovary, from which it "picks up" the ovulated egg from the ruptured follicle. It's composed of delicate fimbriae -- finger-like projections of the tube lined by cells with tiny hairs (cilia), which beat towards the inside of the tube, carrying the sticky cumulus mass containing the egg into the ampulla before fertilisation. Easily damaged by infection (salpingitis) or careless surgery, after which it may be blocked, resulting in a hydrosalpinx, or have its correct movement inhibited by adhesions.

Normal structure in the ovary that contains the egg, or oocyte. All are formed as primordial follicles before birth and remain microscopic in size until growth starts (folliculogenesis), a month or two before the cycle in which the particular follicle will be a candidate to ovulate. About 3 mm in diameter at the start of a cycle, and about 2 cm in diameter when ready to ovulate. The follicle makes more and more estrogen (particularly estradiol) as it grows. In ovarian monitoring for assisted conception, the number growing and their rate of growth are monitored by transvaginal ultrasound.

Egg retrieval procedure for obtaining eggs (oocytes), involving the passing of a needle into a mature (or preovulatory follicle), either directly at laparoscopy or (more usually) via the vagina guided by transvaginal ultrasound.

Serial transvaginal ultrasounds of the ovary during the follicular phase to track the growth of one or more tertiary follicles, accompanied usually by serial estimations of serum estradiol, serum LH and serum progesterone, for the two-fold purpose of estimating follicular maturity (to time intercourse, a mid-cycle-dependent investigation such as a postcoital test, or an egg retrieval) and identifying the onset of the LH-surge, which can affect the timing of the intervention. Sometimes accompanied by injection of human chorionic gonadotropin to trigger ovulation at a precisely anticipated time.

The part of the ovary's monthly cycle before ovulation, dominated by the presence of firstly, a cohort of growing tertiary follicles, then the dominant follicle, and the estradiol these follicles produce. Normally around 14 days in length, but quite variable, often being much longer for the first few menstrual cycles after the first period (menarche), and typically getting shorter in the months or years leading up to egg depletion and menopause. Corresponds with the proliferative phase of the endometrial, or menstrual cycle.

A follicle is "recruited" at two distinct stages of development. Early or continuous recruitment refers to the ongoing, continuous recruitment of primordial follicles to start their growth and become antral follicles, a process that is independent of major hormones, starts before birth and ends when there are no follicles left, this taking place around the time of menopause. Cyclical recruitment refers to the much later recruitment of medium-sized tertiary follicles into the ovarian cycle due to a temporary elevation of follicle stimulating hormone, which occurs at the end of each luteal phase, thus initiating a new follicular phase; the group of "recruits" susceptible to this late recruitment is called a cohort. Time-wise for a particular follicle, the two episodes of recruitment occur 8 months apart: in other words, it takes 8 months for a follicle to grow from its resting state before it can have a chance of making estrogen and then undergoing ovulation. Not all early-recruited follicles undergo later cyclical recruitment: some are lost through early atresia, many reach the stage at which they could be cyclically recruited at a stage when FSH is low (most stages of the ovarian cycle) and undergo atresia then. Readers will appreciate that ovulation induction, including intentional superovulation, can have no effect on the rate at which follicles are used up in ovaries or on the age at which menopause will occur (the different recruitment points involved are 8 months apart, with the early recruitment point governing the rate eggs are used up and the late recruitment point deciding how many follicles can respond to provide useable eggs.

Recombinant follicle stimulating hormone made by Organon. Called Puregon in Europe, Australia and Asia. On an equivalent dose basis, produces serum FSH that are somewhat slower to rise than with the use of hMG preparations, but which are ultimately higher: in other words, follicles and serum estradiol levels take a little longer to respond than they do to Humegon, but the number of mature, preovulatory follicles available for egg retrieval is the same or more. I find that 200 U (units) of Puregon per day produces a similar result to 225 U of Humegon or Metrodin. Generically known as follitropin beta.

Generic name for Dimetriose, a drug used in the treatment of endometriosis that inhibits ovulation and blocks the action of both estrogen and progesterone; risks and side effects are similar to danazol; it is usually taken just twice weekly, by mouth.

Any hormone that switches on the function of the gonads. There are two main families of gonadotropins: (a) the gonadotropin that stimulates the growth of the follicle, or follicle stimulating hormone (FSH); and (b) those that cause ovulation from the mature follicle and stimulate the corpus luteum that results to develop and to produce progesterone, namely luteinising hormone (LH) and human chorionic gonadotropin (hCG). FSH will cause growing follicles to produce the estrogen estradiol, provided that a small amount of LH (or hCG) is present. FSH and LH are produced in the pituitary gland, whereas hCG comes from the placenta in pregnancy. In men, FSH stimulates the Sertoli cells of the testicular tubules, and hence drives spermatogenesis; LH and hCG stimulate the Leydig cells to produce testosterone.

A hormone produced by the hypothalamus of the brain to regulate production and release of the gonadotropins follicle stimulating hormone and luteinising hormone. Can be administered to induce ovulation when it is deficient (particularly in amenorrhea due to weight loss or excessive exercise), but it has to be given in small amounts directly into a vein, every 60 to 90 minutes for the two weeks of a normal follicular phase (with an electronic syringe-driver), mimicking its natural pattern of secretion.

Synonym for preovulatory follicle. A large, mature tertiary follicle that will respond to an adequate LH surge or injection of human chorionic gonadotropin (hCG) by undergoing ovulation, releasing its egg. Produces estradiol and, with exposure to LH or hCG, progesterone. Named after Reijnier de Graaf (1641-1673), the first person to see and to appreciate the importance of the ovarian follicle.

(hCG) A gonadotropin produced by the placenta in pregnancy (specifically it's produced by the trophoblast of the chorionic villi); the hormone measured in performing a pregnancy test. The generic (no frills') name for Pregnyl and Profasi, which are preparations of hCG obtained by extracting it from the urine of pregnant women, and Ovidrel, which is made by recombinant gene technology. Mimics the action of luteinising hormone (LH), but has a very much longer duration of action -- and this gives hCG considerable advantages over LH in clinical use. Given as an injection to lead to ovulation from a mature follicle 38 hours after the injection; or to stimulate ongoing function of the corpus luteum, particularly its production of progesterone. So it is typically given after a course of follicle stimulating hormone (FSH) in assisted conception (IVF or GIFT) programs and ovulation induction programs 36 hours before the expected time of egg retrieval (or before having sex or IUI), and then sometimes in further, smaller doses to support the luteal phase that follows. Sometimes used with clomiphene. Ovarian monitoring is needed for its correct use with FSH or with clomiphene. hCG treatment can precipitate the ovarian hyperstimulation syndrome (OHSS).

(hPG) A mixture of follicle stimulating hormone (FSH) and luteinising hormone (LH) extracted directly from pituitary glands obtained at autopsies; not used in Australia or elsewhere since 1986, when it was shown that Creutzfeldt-Jakob disease (CJD), a deadly form of dementia, had been transmitted from its use, presumably due to contaminating and infected brain tissue. Before 1986 it had been used mostly for ovulation induction in women with amenorrhea (absent periods) for which other hormones or drugs had not been effective, although sporadic instances of its use for in vitro fertilisation are known in Australia. No new cases of CJD have been reported among former users of hPG since the early 1990s.

A disease syndrome caused by abnormal sub-microscopic structure of cilia, which therefore do not function properly during embryonic life, childhood and adulthood. The consequences are situs inversus, in which the developing internal organs in the embryo rotate randomly (so that 50% of affected people have their heart on the right side of the chest and their liver on the left side of the abdomen), abnormal sinuses, a bad form of chronic bronchitis called bronchiectasis, because mucus is not cleared from lungs properly, and male infertility because the sperm tail (the flagellum) has the same sub-microscopic structure as the cilia and cannot propel the spermatozoon. Curiously, female fertility is often normal or adequate: it seems the cilia of the fallopian tube's fimbrial end still make useful contact with the cumulus mass at ovulation, stopping the egg from getting lost and giving the muscular contractions of the tube the chance to carry the egg down to the ampullary-isthmic junction. Also called Kartagener's syndrome, after the Swiss physician Manes Kartagener, who first described a triad of situs inversus, abnormal sinuses and bronchiectasis.

One of several tests of the ability of sperm to penetrate cervical mucus at the time of ovulation or under the influence of estrogen.

(IUI) A form of assisted conception involving assisted insemination into the uterus, either for donor insemination (DI) or with husband's semen (AIH). IUI can be carried out with a woman's natural cycles or with ovarian stimulation (superovulation) using clomiphene or follicle stimulating hormone, with ovarian monitoring.

Congenital absence of gonadotropin releasing hormone in the hypothalamus (causing, in women, primary amenorrhea and anovulation and, in men, failure of puberty) in combination with a congenitally absent sense of smell.

A sudden and huge increase in production of luteinising hormone by the pituitary gland in response to sustained and substantial levels of estradiol in the blood in women, midway through the ovarian cycle. Causes ovulation about 36 hours after it starts (about 20 hours after its peak). If not suppressed during assisted conception (see GnRH-agonists and GnRH-antagonists) it can start before human chorionic gonadotropin has been given, so spoiling the timing of egg retrieval. Timely production of the LH surge in adult women depends on female conditioning of the hypothalamus and/or the pituitary gland before birth. Detectable by testing the urine with a special kit.

A treatment protocol for using GnRH-agonists that involves their use for more than a week before injections of follicle stimulating hormone (FSH) start for induction of superovulation in assisted conception programs. The advantage is that any temporary rise in luteinising hormone levels and progesterone levels has dissipated before the development is under way of those ovarian follicles from which eggs will be obtained at egg retrieval. The disadvantage, compared with the short protocol, is that higher (hence more expensive) doses of GnRH-agonist and FSH are needed. The GnRH can be started with menstruation or during the luteal phase of the previous cycle.

Early experience with superovulation for in vitro fertilisation, particularly at the original US program in Norfolk VA, saw women patients classified into three classes of responders, depending on how many eggs were obtained at egg retrieval. Poorer than usual outcomes could occur with either a low response or a high response (the high responders generally have polycystic ovaries, with a risk of ovarian hyperstimulation syndrome (OHSS). Many maneuvers have been used to try and retrieve more eggs among low responders, such as starting high dose FSH on day 1, the adding of growth hormone, the avoidance of GnRH-agonists etc., all generally without improving the results. Day 3 serum FSH levels can be high in low responders, indicating a depletion of eggs in the ovaries.

The part of the ovarian cycle between ovulation and the start of a new follicular phase, so dominated by the presence of the corpus luteum and the progesterone it produces. Normally between 11 and 16 days in length. Extended by the action on the corpus luteum of human chorionic gonadotropin (hCG) if implantation of the embryo is successful. Shorter cycles can interfere with implantation (a luteal phase defect). Corresponds with the secretory phase of the menstrual cycle.

(LPD) A luteal phase that is shorter than optimal for a fertilised egg to undergo implantation. Very likely if the luteal phase is shorter than normal (11 to 16 days), but not all luteal phases within this range are innocent. Often caused by a prior defect of the follicular phase or of the development of the ovulating tertiary follicle (the preovulatory follicle) and hence there can be a defect of the egg itself (if ovulation has actually occurred) or there can be a luteinised unruptured follicle -- any of which will either increase the risk of miscarriage or will prevent pregnancy altogether for that cycle. Synonymous with luteal phase insufficiency.

(LUF) Occurs when a reasonably mature tertiary follicle (or preovulatory follicle) receives an LH surge that's enough to make it start producing progesterone, but is not enough to cause it to release its egg through ovulation. The result is that the egg is trapped in the follicle, which to a greater or lesser extent then functions like a corpus luteum, though this stage of the follicle's life is often shorter, giving rise to a luteal phase defect (LPD).

(LH) The hormone, or gonadotropin, produced by the pituitary gland to cause, in women, ovulation of a mature follicle in the ovary, resulting in formation of the corpus luteum; in men, stimulates the production of testosterone by the Leydig cells of the testis. Suppressed by GnRH-agonists and GnRH-antagonists, so that (for ovulation induction) an injection of human chorionic gonadotropin (hCG), which acts the same way, has a predictable time course of action. A small amount of LH is essential for normal function of the tertiary follicle and the corpus luteum. Recombinant LH is under development by Serono as Luveris, but its clinical role in place of hCG is not yet established.

A process similar to mitosis in which two successive divisions of a diploid cell's nucleus result in four 'daughter' cells, each with a haploid number of chromosomes. Unlike mitosis, each chromosome therefore duplicates just once (before the beginning of meiosis). Meiosis in humans (and other higher animals) takes place only among the germ cells (oogonia and spermatogonia, which will have been multiplying by mitosis. By differentiating into, respectively, primary oocytes or primary spermatocytes, each with 92 chromatids, meiosis commences. With completion of the first meiotic division the products (including secondary oocytes and spermatocytes) each contain 46 chromosomes. With completion of the second meiotic division the haploid number (23) of chromosomes, suitable for fertilisation, is reached. In the testis, meiosis and the production of new sperm cells (spermatozoa) can continue throughout life, but in the ovary all egg cells that survive commence meiosis about 20 weeks before birth, spending the remaining time (up to 50 years or more) locked up in primordial follicles as primary oocytes. Whereas a primary spermatocyte gives rise to four haploid sperm cells, a primary oocyte produces just one secondary oocyte (the spare 46 chromosomes are dumped into the first polar body just before ovulation), and then one egg cell (the spare 23 chromosomes are dumped into the second polar body after fertilisation).

The last natural menstrual period (so often a retrospective diagnosis); hence the adjective menopausal, the natural state a woman is in after the ovaries have stopped ovulating because of depletion of eggs. The normal age of menopause is between 40 and 55 years, with an average in Western societies of 50-51 years.

The phase of the menstrual cycle in the endometrium during which there is menstruation, caused by withdrawal of progesterone at the end of the ovarian luteal phase as a new ovarian follicular phase starts; in anovulatory cycles or during treatment with estrogens, menstrual bleeding can occur from withdrawal, insufficiency or downward fluctuations of estrogen alone.

Oral anti-diabetic drug that improves many aspects of the polycystic ovary syndrome, including lowering of androgens, serum LH, insulin levels and weight, in combination with a low calorie diet; improves development of ovarian follicles and ovulation, as well as responsiveness to clomiphene or gonadotropins if ovulation induction or in vitro fertilisation is necessary.

German for ovulation pain.

In our context, the frequent estimation of serum estradiol (or perhaps estimating the cervical score) and performance of transvaginal ultrasound to estimate how close a woman is to ovulation.

(pronounced 'mool-air-ian') Syn. paramesonephric duct. The internal female sex duct, which forms on each side of a female embryo to connect the peritoneal cavity with the outside of the embryo, starting at a point close to the ovary and forming first a fallopian tube then meeting its fellow from the other side to form the uterus, and then extending downwards to form the upper part of the vagina before finally connecting with a little dimple between the urethra (in front) and the anus (behind) to reach the exterior at the vulva. Passage of eggs from the ovaries (which ovulate into the peritoneal cavity of all vertebrate species) to the outside world through this duct is how animals, including humans, reproduce. In males the ducts do not develop because the Sertoli cells of the testes produce anti-Mullerian hormone.

In medicine generally it may be best for tests to be negative (like tests for brain tumors or tests for sexually transmitted diseases such as HIV -- as for 'histories', compare negative history), but this is not always so in infertility. Infertility tests are generally better if they're positive, like the postcoital test, tests for ovulation, tests for tubal patency, and (not least) a pregnancy test.

Nonsteroidal anti-inflammatory drugs, e.g. aspirin, ibuprofen (Advil, Nurofen etc), mefanamic acid (Ponstan), naproxen sodium (Aleve, Naprosyn, or in Naprogesic in combination with dextropropoxyphene), which stop the production of prostaglandins; useful for dysmenorrhea and prior to a hysterosalpingogram. Excessive use at the time of ovulation might predispose to a luteinised unruptured follicle, so NSAIDs should not be used for ovulation pain if you are trying to get pregnant.

The equivalent of the menstrual cycle in the ovary, comprising the follicular phase and the luteal phase. Thus the ordered sequence of timely development of tertiary follicles to a (usually) single dominant follicle or Graafian follicle, characterised by increasing production of the estrogen estradiol), through ovulation, when estradiol falls and progesterone starts to rise, followed by the development and then decline of the corpus luteum, with the further production of progesterone. Because estradiol and progesterone control the growth and development of the endometrium in the uterus, the ovarian cycle determines the menstrual cycle (normally lasting from 24 to 35 days in length, and with a typical duration of about 28 days) and also the cycle of the normal female hypothalamus and pituitary gland.

(OHSS) A complication of ovulation induction with, usually, follicle stimulating hormone, especially in cycles of superovulation for assisted conception, when it is intended to retrieve more than one egg. The ovaries become large, they can be painful, and there is excessive fluid released into the abdomen (the peritoneal cavity). Either removing this fluid or the occurrence of vomiting can cause dehydration, thickening of the blood and, occasionally, a serious thrombosis, such as a stroke. Death has been reported. Moderate to severe OHSS is treated in hospital, with administration of fluid intravenously, sometimes including albumin.

The frequent estimation of serum estradiol (or perhaps estimating the cervical score) and performance of transvaginal ultrasound to estimate how close a woman is to ovulation.

The female germ cell, or egg, from the earliest stage (the oogonium in the fetus), through its release from the follicle (ovulation), and (to professional embryologists) through fertilisation up to and sometimes beyond the stage of implantation. Plural: ova.

A time of intermittent symptoms of the menopause that first becomes apparent as egg numbers in the ovaries fall far enough to cause shortening of the menstrual cycle, particularly the follicular phase, and accompanied by elevation of serum FSH when measured during menstruation. As it progresses, menstrual cycles can shorten considerably, while becoming interspersed unpredictably by unusually long cycles, sometimes producing cystic follicles and even anovulatory dysfunctional bleeding, as well as episodes of hot flashes. Different from the oopause.

A tumor, usually benign, of the pituitary gland, usually resulting in amenorrhea and anovulation. Often there is an increase (sometimes substantial) in serum prolactin. If the tumor is itself secreting prolactin it is called a prolactinoma. But other tumors can occur, some of which secrete other pituitary hormones. The tumor grows inside a confined space with walls of bone called the pituitary fossa: if it is still small and confined to the fossa we call the tumor a microadenoma; if it enlarges the fossa or pushes out of it, it is a macroadenoma, and is both more dangerous and capable of producing visual symptoms and headaches. Diagnosed on a CAT scan or a MRI scan. Prolactin-secreting microadenomas can usually be treated just with drugs.

A tiny, compact packet of excess chromosomes discarded first by the primary oocyte as it becomes a secondary oocyte just before ovulation -- the first polar body, with 46 chromosomes; and second by the secondary oocyte immediately after fertilisation (or after activation by other means) -- the second polar body, with 23 chromosomes. The polar bodies lie in the perivitelline space. The chromosome content of each polar body can be tested as part of a preimplantation diagnosis maneuver to infer whether the corresponding oocyte has an aneuploidy: an extra chromosome in the polar body means a chromosome not enough in the oocyte, and vice versa; this is called polar body analysis.

In medicine, it might generally be best for tests to be negative (like tests for brain tumors or tests for sexually transmitted diseases, such as HIV -- as for medical histories, compare positive history) -- but not so in infertility. Infertility tests, such as the postcoital test, tests for ovulation, tests for tubal patency, and (not least) a pregnancy test, are generally better if they're positive.

(PCT) A test of: (1) receptiveness of the cervical mucus to sperm; and (2) sperm motility -- both of which are needed for the test to be a positive test. It's essential that the test be done to coincide with ovulation, tested with a urinary LH kit or measurements of serum estradiol (high), serum LH (preferably high) and serum progesterone (still low), because the job description of the cervical mucus at other times is to be impenetrable to sperm (i.e. the PCT will be negative for normal reasons).

(PMT) A distressing group of symptoms usually timed for the lead up to a period, then relieved as menstruation takes place, although many women experience different timing; includes downheartedness or depression (certainly an absence of well-being), aggression, fluid retention and weight gain, painful breasts ('mastalgia'), headaches and pain in the pelvis; caused by a periodic fall in the brain's endorphins, in turn usually precipitated by falling levels of progesterone in the second half of the luteal phase, although similar symptoms often accompany the use of progestogens, especially in older women; may be better during superovulation cycles because of generally higher hormone levels, but this is not always the case and PMT at the end of an unsuccessful cycle of assisted conception is particularly hard to put up with. Usually treated (up to a point) symptomatically, with perhaps fluid tablets (diuretics) and analgesics, although it's claimed that the drug Prozac has a specifically beneficial effect on mood, and encouragement of endorphin release with exercise can also be useful. Because progesterone and progestogens are the culprits, an operation to remove the ovaries (plus hysterectomy to simplify estrogen replacement therapy without needing progestogens) is usually curative, but drastic.

The form of the ovum, or egg, produced in the ovaries of fetuses by oogonia that have begun the first part of the cell division known as meiosis (by which the chromosomes will eventually halve in number). Persists into childhood and adult life by containment in follicles. Gives rise to a secondary oocyte and the first polar body just before ovulation.

The ovary's second main hormone, produced only after ovulation and during pregnancy (first by the corpus luteum, then by the placenta). Sometimes administered by injection or by insertion into the vagina in the form of a pessary to supplement natural production.

Recombinant follicle stimulating hormone made by Organon. Called Follistim in US. On an equivalent dose basis, produces serum FSH that are somewhat slower to rise than with the use of hMG preparations, but which are ultimately higher: in other words, follicles and serum estradiol levels take a little longer to respond than they do to Humegon, but the number of mature, preovulatory follicles available for egg retrieval is the same or more. Professor Jansen, medical director of SIVF, notes that 200 U (units) of Puregon per day produces a similar result to 225 U of Humegon or Metrodin. Generically known as follitropin beta.

An insulin-like protein with quite different functions. As the name suggests, tissues soften, relax or give-way upon exposure to it. Produced, for example, in the wall of the preovulatory follicle before ovulation, by the decidua to calm the myometrium of the pregnant uterus, and by the corpus luteum and the placenta to soften the ligaments of the pelvis in preparation for labor and childbirth.

The form of the oocyte, or egg, produced from the primary oocyte late in the life of the maturing follicle, just before ovulation. The egg stays at this stage until fertilisation by a sperm cell (spermatozoon).

Failure of ovulation along with low estrogen production from the ovaries because of insufficient signalling from the pituitary gland by its hormones, the gonadotropins.

Measurement of estradiol in blood serum. Used especially for monitoring the development of ovarian follicles in assisted conception, usually together with transvaginal ultrasound. The cycle might be a natural one or, more usually, when there is ovulation induction or superovulation. The result should be available within 4 hours of the test for this purpose.

Measurement of progesterone in serum. Often measured to check the occurrence of prior ovulation. Used to infer the onset of ovulation in ovulation induction or assisted conception programs, and attaches extra significance to an apparently raised serum LH in judging the onset of the LH surge during monitoring. The result should be available within 4 hours for these purposes. Abbr. serum P4.

A treatment protocol for controlled stimulation of the ovaries using GnRH-agonists with injections of follicle stimulating hormone (FSH) for induction of superovulation in assisted conception programs involves starting the GnRH-agonist a day or two before the injections of FSH start. The advantage is one of cost: less FSH (and less GnRH-agonist) are used compared with the long protocol. The disadvantage is that luteinising hormone levels and progesterone levels can rise, possibly (in some cycles of treatment) spoiling optimal development of ovarian follicles. The GnRH-agonist is continued (in contrast to the ultrashort protocol) until follicles are mature and human chorionic gonadotropin is given to start the process of ovulation.

A general term used by obstetricians or pediatricians to refer to a fetus or newborn baby that seems smaller than it should be for the assumed duration of the pregnancy so far. The three main causes are a genetic abnormality of the fetus; insufficient nutrition for an otherwise normal fetus; and an incorrect calculation of the dates, maybe because ovulation and conception took place later than the usual two weeks after the last menstrual period. Recent research shows that women with infertility might be at higher risk of small-for-dates babies when they do get pregnant.

The state of absolute infertility or complete infertility, with no chance of getting pregnant without special help. Causes include azoospermia, anovulation (especially primary ovarian failure), and blocked fallopian tubes.

Twisting of an organ on its vascular pedicle, risking necrosis. Can happen to the testis in boys, especially after an injury to the scrotum, or to the ovary and fallopian tube, either spontaneously during adolescence or when enlargement from superovulation has produced ovarian hyperstimulation syndrome (OHSS). An operation to untwist it can save the affected organ, if carried out quickly enough.

Surrogacy in which the woman who is the surrogate for the intended pregnancy provides the eggs (through her own ovulation); is impregnated by assisted insemination; carries (or 'gestates') the pregnancy; gives birth; and then gives up the baby to the person who commissioned the surrogacy arrangement. Also known as genetic-plus-gestational surrogacy. The surrogate is as much the biological mother of the child as if she had conceived in natural circumstances, except that the male by whom she has been impregnated has no prior social relationship with her. No countries other than the US, where commercial surrogacy can be legal, have encouraged the practice, whether for altruistic or commercial reasons.

Ultrasound imaging of the pelvic organs for diagnosing abnormalities of (particularly) the uterus and the ovaries; for monitoring the development of ovarian follicles with ovulation induction and assisted conception programs; and for following the course of early pregnancy. Among the pioneers were Dr Karl Popp, who used a mechanical sector scanner vaginally in Hamburg in 1984, and Dr John Anderson, who used the first vaginal linear array scanner at Sydney IVF in 1985, leading to its widespread use subsequently in Australia and the US.

A variation of the short protocol for using GnRH-agonists with injections of follicle stimulating hormone (FSH) for controlled induction of superovulation in assisted conception programs. The GnRH-agonist is started with menstruation, a day or two before the injections of FSH start, and is discontinued after about 5 days from starting it (i.e. often a week or more before ovulation). There are no special advantages, whereas there's a potential disadvantage: a much more thorough suppression of the woman's own luteinising hormone (and maybe FSH) than if the GnRH-agonist is continued -- potentially causing stimulated follicles to 'run out of puff' before they are fully mature. The ultrashort protocol should not be used with pure forms of FSH, such as Fertinex, Gonal-F, Metrodin HP or Puregon, or poor egg quality will result if some luteinising hormone is not administered.

Infertility for which no obvious cause has been found after the following tests have been done with normal results: a sperm count or postcoital test; a test of ovulation, such as a serum progesterone that is satisfactorily high; and a laparoscopy (used to show that the tubes are open and that there is no endometriosis or other obvious abnormality). Although a hysterosalpingogram (HSG) can substitute for laparoscopy in excluding blockage of the fallopian tubes, an HSG can miss peritubal adhesions and will miss endometriosis. Infertility should not be considered unexplained unless a thorough, careful laparoscopy has been done.

A uterine anomaly that comes about when the uterus forms (in the embryo) from just one Mullerian duct; the uterus will be a little smaller than normal (making a miscarriage or premature labor more likely), and will be connected by a fallopian tube to just one ovary, contributing slightly to infertility (since, on average, only half of ovulations have a chance of resulting in pregnancy). Reproduction, however, can be normal, and a woman might go through life with a unicornuate uterus and not know it. Diagnosed by hysteroscopy and laparoscopy, by hysterosalpingogram or -- particularly effectively -- by three-dimensional ultrasound. Often there is a simultaneous abnormality of the kidneys, such as one kidney instead of two, diagnosable by abdominal ultrasound or, more specifically, by a special kidney x-ray study called an intravenous pyelogram.

A home test for ovulation in which the urine is tested for luteinising hormone. If the urine shows a positive test, ovulation will usually take place within 24 to 36 hours. Electronic devices that perform the same function are available (and are increasingly popular in the U.K.).

(VEGF) A growth factor (or local hormone) needed for new blood vessels to form in, for example, the corpus luteum, as it turns into an efficient hormone-producing gland making and releasing progesterone about a week after ovulation. Because such new blood vessels are rather leaky, excess VEGF from multiple corpora lutea during ovulation induction or superovulation using gonadotropins can be associated with new blood vessels trying to form in the general peritoneal cavity, leakage of fluid from which causes fluid to build up in the abdomen, a potentially dangerous condition known as the ovarian hyperstimulation syndrome. VEGF is also important in the formation of the placenta, so mutations of VEGF or its target proteins can cause recurrent miscarriage.