Fertility Consultations Insider: Diagnosing An Ovulation Disorder

Monday, October 21, 2019
Fertility Consultations Insider: Diagnosing An Ovulation Disorder

In September 2019, Holly K. requested a Private Consultation with me and her inquiry was:

“I'm 24, my partner is 30 and we’ve been trying to conceive for about 5 years now. 

I'm not sure if I'm infertile or not. I got pregnant 4 months ago and had miscarriage at 4-5 weeks. This was my first miscarriage I didn't really experience any pain just bleeding and clots. They also found a cyst on my ovary. Could that cause me to be infertile?"

After exploring her answers to my In-Depth Questionnaire, more information emerged:

Holly's periods are very heavy sometimes and they are irregular, there are months when she won’t have a period at all. Her periods are not really painful except when there’s heavy bleeding. 

She's had a transvaginal ultrasound 4 months previously and that's how she found out about her miscarriage and the cyst on her ovary. She wasn't told any additional details about this cyst and received no paperwork of her ultrasound.

Here was my answer to her:

Hi Holly

You mentioned you have been trying to conceive for 5 years.This, especially at such a young age, usually suggests a fertility issue that needs to be investigated further. In your case, I’m suspecting a likely ovulatory disorder (in other words, the ovulation doesn’t happen regularly and in some months may not even happen at all). This would explain why your periods are irregular and sometimes even missing for a longer time. It would also explain why sometimes the flow is very heavy (the uterine lining keeps building up in lack of ovulation and when it does eventually shed, there’s a lot of it to come out). 

A very common cause of ovulatory dysfunction is PCOS (Polycystic Ovary Syndrome). It is believed to affect as many as 1 in 10 women worldwide. You can have this condition and not even know it. A few common symptoms of PCOS: 

• Excessively long and irregular menstrual cycles that are more than 35 days in length and less than 9 per year in total

• Ovulations that may happen erratically or it might not happen at all for some women.

• Polycystic ovaries on ultrasound (despite its name, you can STILL have PCOS even without this feature)

• Excess body hair in certain locations like the face, chest and abdomen

• Acne and oiliness of skin and hair

• Hair loss

• Obesity or weight gain 

• Infertility and miscarriage

• Insulin resistance (pre-diabetes)

You don’t need to have ALL the above symptoms to have PCOS - but if you have more than 2, I think it’s worth looking into it as a possibility. The great news is that if this is the culprit, PCOS is very treatable from a fertility perspective. Most women who have PCOS achieve pregnancy within months of treatment. The treatment involves healthy lifestyle changes (losing weight if overweight, exercising if sedentary, keeping a low carb diet) and medications that help regulate hormones and trigger ovulation - like Clomid, letrozole (Femara), metformin (when there is insulin resistance) and others. There are quite a few options available should this be the case. The treatment can help you start ovulating regularly and increase the odds of pregnancy every month.

My advice is that you should definitely discuss the possibility of PCOS or other ovulatory disorder with your doctor, preferably an OBGYN. Irregular cycles are a very clear sign of an ovulation problem and this can hinder your ability to become pregnant and even keep a pregnancy. 

I’m so sorry for your miscarriage. It is heartbreaking to lose a pregnancy that is achieved after such a long time of trying. I can promise you that you can and you will become pregnant again. You can also ask yourself, did you do something different that month in which you became pregnant, was there anything that was new or different to your TTC routine or maybe even your life in general? If something does stand out, try to recreate or redo those steps that seemed to have worked for you, in your next cycles.

Lastly, about the cyst that was found on your last ultrasound - I cannot be absolutely sure without a medical report of the ultrasound - but it’s highly likely that it was a luteal cyst. A luteal cyst is what produces progesterone during the second half of the menstrual cycle and during the first trimester of pregnancy and it is very normal and even expected to be seen during pregnancy. In some cases a luteal cyst can get quite large, up to 5-8 cm. The luteal cyst will break down and disappear in lack of a pregnancy, so within 2-3 months this cyst should be gone, however a different luteal cyst may appear in the meantime, since a new luteal cyst develops after each ovulation. 

I hope my answer sheds some light into the likely cause of your difficulties with getting pregnant and will guide you towards fixing the problem that has been holding things up in your case.

In conclusion: the likely cause of your fertility issues is an ovulatory dysfunction, possibly PCOS. The cyst found on your ultrasound is very unlikely to cause infertility and is probably a functional luteal cyst. Your next step should be seeing an OBGYN to have a follow-up ultrasound and check on the cyst and count the number of follicles on each ovary. You will benefit from a treatment that stimulates regular ovulations (Clomid or Letrozole are the best first choices).


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