Anovulation and ovulation problems: causes, tests and treatment in the UK

Each month in a typical cycle an ovary releases an egg, which travels along a fallopian tube where it may meet sperm. If this does not happen, pregnancy cannot occur. The NHS explains that infertility is commonly caused by ovulation problems, and that some stop an egg being released at all while others prevent release in some cycles but not others.

Because ovulation is closely tied to the menstrual cycle, the first clue is often irregular or absent periods. The NHS lists irregular periods or long gaps between periods as a main symptom of PMOS, and notes that when you have irregular periods you will be offered a hormone test to look at the signals that stimulate the ovaries.

Anovulation is a cause of infertility rather than a single disease. The aim of assessment is to find the reason, because that determines the treatment. The NHS says that for 1 in 4 couples a cause cannot be identified, which is a reminder that ovulation is only one part of the picture.

The NHS lists three main reasons for ovulation problems. Polyendocrine metabolic ovarian syndrome (PMOS), previously called polycystic ovary syndrome, is a hormone condition that the NHS says can affect hair growth, periods, fertility and mood; its cause is unknown but may involve hormones such as insulin and testosterone not working properly. Thyroid problems, both overactive and underactive, can prevent ovulation. Premature ovarian failure means the ovaries stop working before age 40.

Other factors affect ovulation indirectly. The NHS says that in women being overweight or obese (a BMI of 30 or over) or severely underweight can affect ovulation, that smoking affects the chance of conceiving, and that in severe cases stress may also affect ovulation and sperm production. Some medicines and drugs can interfere too. The NHS lists chemotherapy, which can sometimes cause ovarian failure, antipsychotic medicines, which can sometimes cause missed periods or infertility, long-term or high-dose NSAIDs, spironolactone, and illegal drugs such as cannabis and cocaine.

Age matters. The NHS says fertility declines with age, and that the decline speeds up when reaching the mid-30s.

The NHS says more than 8 in 10 couples, where the woman is under 40, will conceive naturally within a year of regular unprotected sex, which means every 2 to 3 days. You should see a GP if you have not conceived after a year, and sooner if you are 36 or over or have another reason to be concerned, such as treatment for cancer or a possible sexually transmitted infection.

The NHS lists irregular periods or long gaps between periods, excessive hair growth, oily skin and acne and difficulty getting pregnant among the symptoms of PMOS, and advises seeing a GP if symptoms are affecting everyday life. Raising these early is reasonable, since the NHS says fertility tests can take time. The NHS recommends that both partners attend because fertility problems can affect either or both.

The GP will ask about periods, previous pregnancies, how long you have been trying, sex, medicines, lifestyle and medical history, and may weigh you and examine your pelvis. They may then refer you to a specialist fertility team for tests.

The NHS lists the tests for women: a blood test for progesterone to check whether you are ovulating, timed according to how regular your periods are; a test for gonadotrophins if periods are irregular; a chlamydia test because the infection can affect fertility; and an ultrasound scan to check the ovaries, womb and fallopian tubes. If a blockage is suspected, further checks such as a hysterosalpingogram, hysterosalpingo-contrast-ultrasonography or a laparoscopy may be considered. For PMOS the NHS says tests include blood tests for hormone levels and insulin resistance and an ultrasound scan of the ovaries.

A semen analysis is usually part of the work-up, because male factors are also common and the NHS notes that problems can affect either partner.

The NHS says that treatment depends on the cause and on what is available from your local integrated care board (ICB). The three main types are medicines, surgical procedures and assisted conception. For ovulation problems, medicines are usually the first step.

The NHS says for women with PMOS that a healthy balanced diet, regular exercise and losing weight if overweight can help, and that weight loss and activity are also supported by NHS Better Health tools. Stopping smoking and keeping alcohol low are advised: the UK chief medical officers recommend no more than 14 units a week spread over 3 days or more, and the NHS says the safest approach when trying to conceive is not to drink alcohol at all.

The NHS says that infertility is usually only diagnosed and treated after 2 years of trying, but that fertility tests can take time and fertility declines with age, so it is best to make an appointment early. For couples who have been trying for more than 3 years, the NHS says the likelihood of conceiving naturally within the next year is 1 in 4 or less. Many people with an ovulation problem do conceive with treatment, but the sources reviewed here do not give a single success figure, as it varies with cause, age and other factors.

Trying to conceive can be an emotional process, and the NHS encourages partners to support each other. For PMOS, charities such as The Verity, the British Fertility Society and The Lowdown provide information and support.

The NHS says funding for fertility treatment varies across the UK, waiting lists can be long in some areas and eligibility criteria vary, so a GP or your local ICB can explain what applies to you. The NHS pays for initial investigations and specialist referral, and all patients have the right to be referred to an NHS clinic for those.

Private treatment is available, but the NHS says it can be expensive and that there is no guarantee of success. Choose a clinic licensed by the Human Fertilisation and Embryology Authority (HFEA), ask for a fully costed personalised treatment plan, and compare success rates, waiting times and what is included. The NHS notes there is no evidence that complementary therapies for fertility problems are effective.