Objectives: To describe our management strategy of ovulation disorders. Patients and methods: From a retrospective collection of data from the records, we identified over a period of one year (January 2016-December 2016), 47 patients followed in gynecology department of University and Hospital Centers of Yopougon and Treichville in Abidjan (Cote d ’ Ivoire) for ovulation disorders. The diagnosis of dysovulation was made following a hormonal check up and a follicular monitoring ultrasound. These patients underwent a specific treatment according to the type of dysovulation they presented. Results: The average age was 31.9 years with a significant proportion of nulliparous (66%). Body mass index was high in 44.7% of patients, of whom 19.1% were obese and 25.6% overweight. The hormonal balance was disrupted in 48.9% of cases. Polycystic ovary syndrome (WHO type IIb dysovulation) was the most common pathology (36%). The proposed treatments were dominated by clomiphene citrate (31.9%) and gonadotrophins (25.5%). 14.9% of pregnancies were obtained. Conclusion: This study allows us to offer better management of ovulation disorders, but this necessarily entails a careful exploration and an appropriate treatment.
Ovulation disorders account for 30% - 35% of female infertility [
This was a retrospective and cohort study with descriptive purpose conducted from 1st January 2016 to 31st December 2016 (12 months period), in the gynecology department of University and Hospital Centers of Yopougon (CHUY) and Treichville (CHUT) in Abidjan (Côte d’Ivoire). The study involved women who came to consult for infertility and whose spouses had a normal spermogram. We included patients who had an endovaginal ultrasound which evoked the diagnosis of dysovulation and who achieved the hormonal balance required, and followed the treatment indicated for this purpose. We excluded patients with uterine and tubal abnormalities, and those who had incomplete files. Thus, our study concerned 47 patients.
Women who consult in our services for infertility must achieve a minimal check up including an endovaginal ultrasound exploration, a hormonal balance, hysterosalpingography, and a spermogram at their spouses.
- Endovaginal ultrasound exploration: The ultrasound exploration of the ovulation required an endovaginal ultrasound for follicular monitoring: this monitoring of ovulation necessitated peri-ovulatory ultrasounds on the 8th, 12th and 16th day of the cycle, aiming at objectifying the dominant follicle and then monitoring its growth until eventual ovulation.
- The hormonal balance: It was carried out on the third day of the cycle and consisted of a blood dosage of the following hormones: FSH, LH, Estradiol, Prolactin. We considered as cut-off acccording to Merviel [
The data were collected after the examination of the files of the patients covering the period of study on a fact sheet prepared for this purpose. The analysis of the data entered was carried out with the software EPI-INFO 6.04.
The CHUY and CHUT are level 3 center of the heath pyramid in Côte d’Ivoire. And during the study period, we received 1135 couples for infertitlity including 623 in CHUy and 512 in CHUT. Among this couples, 47 women met our inclusion criteria.
The average age of our patients was 31.9 years with the extremes at 18 years and 43 years. A peak frequency was observed between 30 and 34 years (57.4%), and 38.3% of our patients were between 35 and 45 years old. 2/3 of our patients (66%) were nulliparous, and 70.2% had a duration of infertility between 2 and 4 years. Almost half of our patients (46.8%) had an irregular cycle while 53.2% of our patients had a cycle time of 28 to 31 days. The average body mass index (BMI) of our patients was 25.33. Among these patients, 55.3% had normal weight, 25.6% were overweight and 19.1% were obese.
Twenty-three patients (48.9%) had a hormonal upset: FSH > 12 mIU/ml in 5 patients; LH > 8 mIU/ml in 7 patients; Isolated hyperoestrogenism >70 mIU in 3 patients; Hyperoestrogenism associated with high FSH in 3 patients; Hyperprolactinemia in 5 patients.
A typical echographic appearance of PCOS was found in 36.2% of our patients. In 31.9% of patients, slow follicular growth was observed . A follicular cystitis was encountered in 21.3% of cases (
Clomiphene citrate and gonadotrophins were the most commonly used ovulation inducers. They accounted for 2/3 (68%) of the proposed treatments (
Seven patients (14.9% of our study population) had a pregnancy. It was a single pregnancy.
All our pregnant patients (7) had a normal initial hormonal balance.
TYPE OF DYSOVULATION | POPULATION | PERCENTAGE (%) |
---|---|---|
- Follicular cyst | 10 | 21.3 |
- PCOS (type II b) | 17 | 36.2 |
- Poor follicular ovary (type III) | 5 | 10.6 |
- Follicular growth retardation | 15 | 31.9 |
Total | 47 | 100 |
PCOS: polycystic ovary syndrome.
TREATMENT RECEIVED | POPULATION | PERCENTAGE (%) |
---|---|---|
- Diet | 4 | 8.5 |
- Clomifene Citrate | 15 | 31.9 |
- HMG or FSH (Gonadotrophins) | 12 | 25.5 |
- Clomifene citrate + Diet | 4 | 8.5 |
- Clomifene citrate + HMG or FSH | 5 | 10.6 |
- Clomifene citrate + cabergoline | 2 | 4.3 |
- HMG or FSH + Diet | 2 | 4.3 |
- Diet + Cabergoline + Metformin | 3 | 6.4 |
TOTAL | 47 | 100 |
57.2% of the pregnancies (4 patients) occurred after 3 cycles of treatment (
Drug treatments were undertaken in 6 patients (85.7%) before they got pregnant (
This study has some limitations linked to the weakness of the sample because all the patients could not afford the cost of management. Thus many patients having not been able to perform the explorations or treatments needed were excluded from the study.
In our study, the average age was 31.9 years with the extremes at 18 years and 43 years.
Patients aged between 30 and 34 accounted for more than half of our population (57.4%). Our finding is identical to that of SCHWART [
The rate of conception per cycle varies according to age: it is 24% at 25 years, 12% at 35 years and 6% at 40 years [
NUMBER OF CYCLES | POPULATION | PERCENTAGE (%) |
---|---|---|
1 | 2 | 28.6 |
2 | 1 | 14.3 |
3 | 1 | 14.3 |
7 | 1 | 14.3 |
12 | 2 | 28.6 |
TOTAL | 7 | 100 |
TYPE OF TREATMENT RECEIVED | POPULATION | PERCENTAGE (%) |
---|---|---|
- Clomifene Citrate | 2 | 28.6 |
- FSH or HMG | 3 | 42.8 |
- Clomiphene citrate + Diet | 1 | 14.3 |
- Diet | 1 | 14.3 |
TOTAL | 7 | 100 |
In addition to age, being overweight can be a factor in ovulation disorders. According to OLIVENNES, weight is the first factor to consider: a weight too low (<45 kgs) or an obesity (>85 kgs) are responsible for ovulation disorders [
In our study population, 46.8% of patients had an irregular cycle. LANSAC [
The duration of infertility would have a pejorative role on procreation: the older the infertility, the lower the chance of getting pregnant [
The age of the patient and the duration of infertility are therefore two essential parameters to be taken into account.
Several patients in our series (48.9%) had a disturbedhormonal balance. The studies carried out by FRYDMAN [
In our study population, PCOS were the most important echographic aspects of dysovulation (6.2%). Our finding is similar to that of TEISSIER [
The treatments used were essentially clomiphene citrate, gonadotropins and diet,accounting for 57.4% of all treatments. Like us Dickey reported a series where he resortedto clomiphene citrate in first-line and to gonadotrophins in second-line [
14.9% of our patients got pregnant after treatment. DICKEY, meanwhile, reported pregnancy rates of 20% - 40% with clomiphene citrate and 12% - 24% with gonadotrophins [
In our study, 4 out of 7 patients were able to obtain a pregnancy after 3 cycles of treatment.
Our results are consistent with those of DICKEY [
Therefore it is reasonable, beyond six cycles of stimulation well conducted to consider to resortto medically assisted procreation (MAP) rather than to relentless pursuit of stimulation.
The purpose of the treatment being to achieve a progressive pregnancy, it is therefore essential to evaluate all the factors of infertility of the couple. The therapeutic strategy should take into account the age of the woman, the duration of infertility, the weight and the type of dysovulation according to the WHO classification.
Thus according to the ageit is not recommanded to use an ovulation induction therapy after 45 years, regardless of the FSH base rate, because the term pregnancy rates are extremely low and fetal and maternal risks are maximum. Concerning the weight, it isadvised that it should be closer to the normal one through hygiene and dietary measures before any ovulation stimulation.
Talking about the dysovulation, WHO gives indications according to their types. The Type I dysovulation called central dysovulation, must be treated by the GnRH pump. The Type IIa or idiopathic dysovulation, must be treated in first intention using clomiphene citrate and gonadotropins in second intention in case of failure to clomiphene citrate after 6 cycles. For the Type IIb or PCOS, first start with the dietary care eventually associated with clomiphene citrate and then in case of failure after 6 cycles of clomiphene citrate, use gonadotropins.An adjuvant therapy with Metformin could also be added.
In the Type III, theuse of the ovulation induction is useless and the couple must be oriented to the MAP with a gametes donationor adoption.
Moreover, in case of hyperprolactinemia, a hypoprolactinaemic must be associated.
This study allowed us to determine the epidemio-clinical factors influencing ovulation in our population. Hormonology showed that the PCOS has been the most common pathology in ovulation disorders. The use of ovulation inductions permitted to correct some abnormalities and obtain pregnancies. However, in order to avoid abusive and blind use of ovulation inductions, prior careful exploration is fundamental.
Mohamed, F., Jean-Marc, D., Stephane, A., Minata, F., Edele, A., Abdoul, K., Marie, K.J., Luc, O., Privat, G. and Mamourou, K. (2017) Therapeutic Approach out of IVF of Ovulation Disorders in Sub-Saharian African. Open Journal of Obstetrics and Gynecology, 7, 1116-1123. https://doi.org/10.4236/ojog.2017.711112