Failure to ovulate (anovulation) is the most common cause of female infertility. Hypogonadotrophic hypogonadism is an uncommon condition where the hormones that are secreted by the brain and operate the ovaries are insufficient. For treatment, the hormones should be replaced with injections. Prior to the treatment a brain MR should be undertaken and the prolactin levels should be determined.

Hypergonadotrophic hypogonadism is the early depletion of the eggs in the ovaries. This is also known as early menapause. There is no know treatment for this condition and the only way for these women to get pregnant is through egg donation.

The most common cause of ovulation failure in women is polycystic ovary syndrome (PCSO). It more commonly occurs in women who are overweight and hirsute (unwanted hair growth). The triad of failure to ovulate, excess hair growth or skin symptoms and/or increased male hormones (androgens), and a special ultrasonographic appearance of the ovaries is called the polycystic ovary syndrome (PCOS). Especially overweight women with polycystic ovary syndrome may also present with insulin resistance (IR). Insulin resistance may increase the production of androgens from the ovary and exacerbate the vicious cycle of PCOS. Approximately 70% of the women who fail to ovulate have PCOS. The treatment of anovulation is usually with medications that induce ovulation.

These are administered stepwise from the least to the most complicated. Initially clomiphene citrate is administered orally. If the woman has IR insulin sensitizers such as metformin should be the initial choice. If the ovaries are unresponsive to the effects of clomiphen citrate or insulin sensitizers administered alone or in combination, gonadotropin injections may be necessary. These are potentially harmful drugs that may cause complications such as hysperstimulation and high order multiple pregnancies (triplets, quadruplets, etc) and thus should be administered with special care only by clinicians who have training in this field.