How does chronic anovulation affect fertility?

Despite being a very common cause of infertility, chronic anovulation is often taken little into account when treating problems in seeking pregnancy. In the first place, because there is a deep ignorance of the menstrual cycle , its different phases and the changes that women go through throughout the month. Secondly, because as soon as there is a fertility problem, it is referred to assisted reproduction treatments. However, there is a lot to do beforehand, such as functional fertility and knowledge of the body and its different manifestations.

Causes of anovulation

At least 25% of infertility cases are the result of ovulation problems . For this reason, the diagnosis and subsequent treatment of the essential cause in the process of seeking and achieving pregnancy will be essential. Behind a person who suffers from anovulatory cycles, or the absence of a menstrual cycle, there are different pathophysiological conditions . It is important to establish a good diagnosis of the patient in order to apply the appropriate treatment and reverse what causes:
  • Functional hypothalamic amenorrhea (absence of menstruation)
  • Polycystic ovary syndrome
  • Thyroid disorders (hyper or hypothyroidism)
  • Hyperprolactinemias
It has been claimed that the only certain evidence that ovulation exists is pregnancy. This means that, although we have sufficient clinical data such as basic gynecological tests or ultrasounds, there are cases of "subclinical" anovulation, where hormonal studies do not inform us of this problem. In addition, the patient may have normal periods and not present any other symptom other than the absence of pregnancy at the time of seeking it. For this reason, in these cases, it is crucial to carry out a thorough study of the woman's medical history, ask the appropriate questions and start a stage of recording and learning about her menstrual cycle .

What can I do to detect if my cycle is ovulatory?

Learning tools that allow us to know the menstrual cycle is a basic starting point to detect this condition. Personally, in consultation I use the symptothermal method, through which, through a record of the temperature and cervical mucus, we can detect in a very simple way if our cycles are ovulatory or not. In the case of patients with amenorrhea , it will be necessary to apply analytical protocols and ultrasound monitoring to achieve a more accurate diagnosis. Variations in cervical mucus and the sensation it produces in the vagina give us very valuable and important information about what may be happening inside the woman's body. In this way, it will be a guide in carrying out diagnostic tests and, therefore, in the efficacy of treatment after diagnosis. Likewise, once the treatment has been prescribed, the recording graph of these variables will give us information on its effectiveness in restoring ovarian function and ovulation control by the gynecologist.

Ovulation physiology, what happens in our hormones?

Ovulation is the response to a process of hormonal coordination in our body in which the following come into play:
  • The hypothalamic-pituitary axis (located in the central nervous system)
  • feedback signals
  • The ovarian response
This system is directly orchestrated by the following hormones : GnRH, FSH, LH, Estrogens, Progesterone, Prolactin, Androgens, Inhibin and Activin, as well as others that indirectly influence our cycle: Thyroid profile (TSH, T3, T3L, T3R, T4, T4L, Cortisol, leptin, insulin…). Finally, we cannot fail to name other substances that, although they are not classic hormones, have a direct impact on the ovulatory process: Prostaglandins and other elements related to our immune system. As if this complex work of teamwork was not enough, the ovary must have a good ovarian reserve, that is, a sufficient number of eggs to be able to ovulate during its fertile stage. During a woman's childbearing years, an oocyte is produced monthly after the mature follicle in the ovary ruptures . This mature follicle is the end of the selection and maturation process of the antral follicles contained in the ovary. In principle, if this oocyte is fertilized, pregnancy will occur , and otherwise, shedding of the endometrium and menstruation will occur. When the ovary runs out of follicles that give rise to new ovulations, the woman enters the stage of normal physiological sterility: menopause , which is why menstruation disappears permanently.

Amenorrhea and other causes of chronic anovulation

Once we understand how the cycle works, we will better understand the classification of the different physiological dysfunctions that can give rise to a situation of anovulation.

Disorders of the uterus and genital canal

First, we must rule out circumstances that cause the absence of menstruation but are not a consequence of anovulation. Some of them are:
  • Asherman's syndrome: destruction of the endometrium with adherence of the uterine walls that occurs after curettage or other severe uterine intervention. This causes the lack of menstruation in the woman, but her ovulation is maintained.
  • Congenital malformations of the genital organs such as Müllerian anomalies and Müllerian agenesis.
  • Androgen insensitivity ( testicular feminization).

ovarian pathologies

Since the ovary is the place where the oocytes are found, ovarian disorders are often accompanied by ovulation problems. We find ovarian pathologies of genetic cause such as Turner Syndrome, mosaicism in sex chromosomes, resistant ovarian syndrome, etc. However, this is not always the case, since they can be secondary to previous treatments with radio or chemotherapy. Another relatively frequent clinical condition is functional hypothalamic amenorrhea , where the woman's body is positioned in "saving" mode, preventing ovulation from being paid for. In the following section, we will delve further into this and into premature ovarian failure, which consists of an early depletion of the ovarian reserve before the age of 40. Despite this, women who experience early menopause may not be definitively infertile. There are documented cases of recovery of ovulatory activity in patients with normal karyotypes and spontaneous ovulations can even occur occasionally. Therefore, we cannot definitively exclude the possibility of pregnancy.

endocrine disruption

As we have seen previously, it is essential to have a good pituitary function for ovulation to take place. The hormones involved in the ovulatory process, such as growth hormone, prolactin, ACTH, TSH, LH, and FSH, are produced by the anterior pituitary gland. We can find pituitary tumors that are mostly asymptomatic and benign, we can also find cysts, tuberculous granulomas and fatty deposits that can compress the pituitary and affect its functioning. On the other hand, it is important to rule out hyperprolactinemia . The main function of prolactin is to stimulate the production of breast milk after childbirth with the consequent withdrawal of ovulation. Apart from lactation, we find elevated prolactins in the following circumstances:
  • Prolactinomas: most common pituitary tumor.
  • Certain drugs: neuroleptics, antidepressants, opioids, etc.
  • Chronic stress situations

Central nervous system disorders

The absence of ovulation and menstrual cycle for more than 3 consecutive months is known as functional hypothalamic menorrhoea (AHF). Functional because it is not a disease in itself, but an adaptation of our body to a certain situation. This absence of menstrual cycle occurs when the body does not have enough fuel with which to carry out all the functions entrusted to it, putting itself in "survival" mode. This inhibits the gonadal axis until you get out of that "fight and flight" situation. In these patients, a pulsatile decrease in GnRH occurs at the physiological level, that is, the hormone that regulates the production of pituitary hormones: FSH and LH. In this way, it is common to observe in this type of patients laboratory tests with practically non-existent levels of FSH, LH, estrogen and progesterone. People who are in a situation of chronic stress (due to energy deficiency, severe weight loss or unresolved emotional conflicts, for example) experience an increase in corticotropin-releasing hormone (CRH), which inhibits the secretion of gonadotropins. This is probably due to the fact that they increase the secretion of beta-endorphins and dopamine, interrupting reproductive function due to this mechanism of action. The fact that said adaptation is a functional response of the body does not mean that it does not have consequences for the health of the woman. Beyond the impossibility of pregnancy, the result of anovulation, it can translate into bone problems due to estrogen deficiency, increased risk of injury, decreased sexual appetite, fatigue , tiredness , cold hands and feet, etc. In these cases, we must place special emphasis on energy expenditure and intake, so that they go hand in hand. We need enough fuel so that the organism has the necessary energy to be able to invest it in gonadal functioning.

What to ask yourself in case of amenorrhea

If this is your case, and you are in amenorrhea, you can stop to reflect on any of these questions and do not hesitate to ask for help, it is the bravest thing you can do for yourself :).
  • Have you drastically increased your level of physical activity without regard to your nutrition?
  • Have you decided to cut out certain foods and do without them?
  • Do you have a circumstance that does not let you sleep at night?
  • Are you happy with your day to day?

If I have functional hypothalamic amenorrhea, can I try to get pregnant?

This is a frequently asked question among patients who present a picture of functional hypothalamic amenorrhea. Even if it costs us, at this point, we have to be honest with ourselves and recognize that perhaps it is not the best time to undergo any type of treatment. Because? Because your body has decided to protect you from ovulation, since it considers that it is not a good time for a potential pregnancy. You have decided that the energy that was destined to maintain the functioning of the menstrual cycle goes to other vital functions to survive. Therefore, at this time, you do not have the necessary energy for the gestation and development of a baby. So what? So you should worry first of all about yourself, about the cause of the absence of menstruation (physical, energetic or psychic), asking for help if you need it.

In short, your body speaks to you and you are responsible for listening and attending to what it wants to communicate to you.

Yes, the body speaks to us constantly, but it does not speak our language, it has its own language: symptoms and signs. Thanks to the symptoms, which often appear abstract (pain, mood swings, tiredness...) and the signs (changes in the cycle, anovulation, amenorrhea, acne...), we can ask the right questions and attend to what it wants to tell us. On most occasions, it asks you for a change in your rhythm of life, to get out of a situation that is not doing you good, a relationship that is toxic to you, a job that does not make you happy... How do we look at these symptoms and signs? We tend to focus on resolving ourselves, but we should look at what's behind them. We'll have to dig deeper to see why they're there and what they've come to tell you. Only in this way will you be able to reverse the origin and find THE key. Finally, let's not forget that this is a two-way process. Your partner should also value certain habits and work on them when necessary. Today I have focused on women's hormonal health, but we will dedicate another entry to fertility problems in men. If you liked the article, do not hesitate to leave your comment and share to whom it may be useful. Thanks for getting here! Fondly, Rocio Periz Faus
Back to blog