Ovulation Woes

One of the most satisfying parts of being an RE is the fact that I can usually predict exactly where a patient is in her menstrual cycle with a blood test and a sonogram. Obstetrics is not nearly this precise. Some women deliver vaginally who you predict would have needed a Cesarean section and others need a Cesarean when you would have predicted a vaginal birth without any help at all. There is no way to predict what will happen in labor, it is all too crazy for me.

During my Fellowship at UCSF I used to moonlight once in a while at the Palo Alto Medical Clinic covering Labor and Delivery for a weekend. It was overwhelming to me. I could not stand to be at home while a patient was in labor, but I was bored at the hospital if labor was going slowly. My wife threatened to kill me. Since she was gainfully employed in the Department of Civil Engineering as an Assistant Professor, we came to the conclusion that it just wasn’t worth the stress.

Of course, one big question is how could you ever leave the perfect climate of Palo Alto, but instead let’s talk about ovulation. Here is today’s “Question of the Day” from 100 Questions and Answers about Infertility:

21. What prevents a woman from ovulating normally?


Regular ovulation is associated with regular menstrual cycles. Predictable monthly periods result from the release of an egg 2 weeks prior to the shedding of the endometrial lining of the uterus and in the absence of pregnancy. If a woman has irregular and unpredictable cycles, then she probably is not ovulating normally. Ovulatory problems are usually divided into two main categories: problems with the ovary and problems with the signals from the brain to the ovary. If a woman’s irregular cycles result from a lack of follicles within her ovary, then the failure of the ovary to respond will cause the pituitary gland to secrete increased amounts of follicle-stimulating hormone (FSH). Women with elevated levels of FSH are described as having diminished ovarian reserve; if their periods cease entirely, then they are described as having premature ovarian failure (POF). Different laboratories may vary as to how they define an “elevated” level of FSH, so a discussion with your physician is crucial to correctly assess the results of this test. In most cases, however, an FSH level of more than 15 IU/L is evidence of diminished ovarian reserve; FSH levels exceeding 30 IU/L usually signify POF. If a woman has a normal complement of follicles but still does not have normal cycles, then the problem must lie elsewhere. Most such women suffer from a communication mismatch between the brain and ovary, which disrupts the carefully coordinated hormone signals that induce the growth of ovarian follicles. The causes of this disruption can be further classified, with most patients being found to have polycystic ovarian syndrome as opposed to other hormonal imbalances.