Causes of Female Infertility – Failure to Ovulate
Dr. Kate Dudek • September 14, 2021 • 5 min read
- A failure to ovulate is the most common cause of female infertility.
- This includes primary ovarian insufficiency (POI) and polycystic ovary syndrome (PCOS) which affect 40% of women with fertility issues.
- If you are not ovulating the first step should be to identify why this is the case, as there are a number of reasons why you may be experiencing a failure to ovulate, also known medically as anovulation.
Polycystic Ovary Syndrome
Polycystic ovary syndrome (PCOS) is a leading causes of female infertility, the predominant reason for anovulation, and the most common endocrine condition affecting women of reproductive age. The fact that up to one in ten women are thought to have the condition, highlights just how prevalent it is.
Furthermore, the strong association of PCOS with insulin resistance and type 2 diabetes, the rates of both of which are continuing to rise, suggests that the incidence of PCOS is likely to increase.
To be diagnosed with PCOS, according to the Rotterdam Criteria, a female needs to present with two out of the three main clinical symptoms; polycystic ovaries, hyperandrogenism, and/or anovulatory cycles. Failure to ovulate does not always mean you don’t menstruate. and it is possible to have PCOS if you have normal periods. You can take a PCOS test cost effectively and discreetly at home by booking via the Nabta Women’s Health Shop.
Not all women with PCOS will be infertile and for many who are struggling to conceive, making lifestyle changes, such as losing weight, can make a big difference.
It has been demonstrated that for women with anovulatory PCOS, a loss of 5% of their body weight was able to restore ovulation. Alternative approaches for restoring common causes of female infertility in women with PCOS include hormonal therapy, medically induced ovulation (clomiphene citrate is usually the drug of choice), and laparoscopic ovarian drilling.
Primary Ovarian Insufficiency
Primary Ovarian Insufficiency (POI), also known as premature ovarian failure, occurs when a female’s ovaries stop secreting hormones and producing eggs at a young age. It is diagnosed when a woman younger than 40 years of age presents with:
-
Amenorrhoea (no periods) lasting more than 4 months
-
Follicle stimulating hormone (FSH) levels ≥ 40 mIU/mL on two occasions.
In POI the follicular pool within the ovaries is exhausted, giving rise to irregular menstrual cycles, low levels of estrogen, and high levels of FSH.
Approximately 10-12% of cases of POI are due to a chromosomal or genetic defect, the most well known of which is a fragile-X syndrome. Fragile X-syndrome is caused by a mutation of the FMR1 gene; it causes mental retardation in men, but not usually in women.
However, females with the mutation have a 13-26% increased risk of developing POI and may experience neurological issues later in life.
There also seems to be an autoimmune component to POI. Addison’s Disease predisposes a female to develop it and there are also associations with other autoimmune conditions, including hypothyroidism. Antibodies targeting FSH are another cause of POI.
Prior cancer treatment increases a woman’s risk of POI, as many cancer treatments have been shown to be gonadotoxic. There is also a suggested link between POI and infections such as HIV, TB, herpes, mumps, and varicella; although no cause or effect relationship has yet been identified.
Despite these known associations and risk factors, for the majority of women, the cause of their POI remains unknown.
For those women at high risk of developing POI, for example, those with a familial link, measuring the levels of anti-müllerian hormone (AMH) in their circulation can serve as a reliable indicator of ovarian reserve. AMH levels correlate with the number of growing follicles.
Even those women with POI who do not wish to conceive may wish to explore treatment options, such as hormone replacement therapy, because prolonged oestrogen deprivation can have serious effects on other aspects of female health, including reducing bone density and increasing the chances of urinary tract infections (UTIs). Oestrogen loss can also negatively impact mental well-being.
Endocrine disorders
Problems with the thyroid gland or the hypothalamus can impact ovulation. One-third of women experiencing fertility issues have thyroid complications. The thyroid gland is located in the neck; its normal function is to produce hormones that regulate metabolism and maintain normal development.
Thyroid hormones play an indirect role in ovarian follicle growth. With insufficient follicular growth, the chances of an egg being released are diminished and with no egg, ovulation cannot occur.
Hypothyroidism
An underactive thyroid results in insufficient thyroid hormone production. The condition is nearly 7 times more likely to affect women than men. In developing countries, hypothyroidism is most frequently caused by a dietary iodine deficiency;
However, in countries with adequate dietary iodine, the predominant cause is Hashimoto’s thyroiditis, an autoimmune disease characterized by the immune system attacking the thyroid and resulting in inhibited thyroid hormone synthesis.
Symptoms of hypothyroidism include fatigue, weight gain, slowness in movements and thoughts, muscular aches, and increased sensitivity to cold. Between 20 and 50% of women with the condition will experience irregular menstrual cycles and/or hyperprolactinaemia. Hypothyroidism can also predispose a female to PCOS-like symptoms.
The first-line treatment approach for hypothyroidism is synthetic thyroid replacement therapy (levothyroxine). For women who are suffering from irregular menstrual cycles due to low thyroid hormone, this treatment is often successful at restoring regular menstrual cycles.
To date, the evidence regarding the use of levothyroxine during pregnancy is inconclusive; as such, women with hypothyroidism who fall pregnant should discuss with their doctor whether or not to continue taking their medication.
In general, it is considered that those women who have TSH levels greater than 4.0 mlU/L are at higher risk of miscarriage, so continued thyroid hormone replacement therapy will often be recommended to improve pregnancy rates.
Functional hypothalamic amenorrhoea (FHA).
Caused by a disruption in the secretion of gonadotropin-releasing hormone (GnRH) from the hypothalamus. This hormone would normally trigger the release of oestrogen from the ovaries, and a lack of it can therefore cause hypo-oestrogenism and anovulation.
FHA disturbs the balance of the hypothalamic-pituitary-ovarian axis and is responsible for 20-35% of cases of secondary amenorrhoea. It can be one of the causes of delayed puberty.
Provided that a congenital condition has been ruled out, some of the most common causes of HPA are an imbalance in energy availability (often due to reduced calorie intake or excessive exercise) and stress.
This means that making lifestyle changes and learning how to manage your emotional well-being can help to alleviate the symptoms of HPA.
This is important because left unmanaged, HPA can affect bone density, increase the risk of cardiovascular disease and predispose an individual to anxiety and depression.
Other causes of ovulation failure
There are other factors that might result in a woman failing to ovulate, or experiencing irregular ovulatory cycles. These include age, as the ovarian reserve diminishes over time, and lifestyle/environmental factors.
Causes for Female Infertility – an Overview
Causes for Female Infertility – Structural issues With the Reproductive Tract
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Get in touch if you have any questions about this article or any aspect of women’s health. We’re here for you.
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Balen, A H, et al. “The Management of Anovulatory Infertility in Women with Polycystic Ovary Syndrome: an Analysis of the Evidence to Support the Development of Global WHO Guidance.” Human Reproduction Update, vol. 22, no. 6, Nov. 2016, pp. 687–708., doi:10.1093/humupd/dmw025.
Chakera, A J, et al. “Treatment for Primary Hypothyroidism: Current Approaches and Future Possibilities.” Drug Design, Development and Therapy , vol. 6, 2012, pp. 1–11., doi:10.2147/DDDT.S12894.
De Vos, M, et al. “Primary Ovarian Insufficiency.” The Lancet, vol. 376, 11 Sept. 2010, pp. 911–921., doi:10.1016/S0140-6736(10)60355-8.
Garber, J R, et al. “Clinical Practice Guidelines for Hypothyroidism in Adults: Cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association.” Thyroid, vol. 22, no. 12, Dec. 2012, pp. 1200–1235., doi:10.1089/thy.2012.0205.
Gude, D. “Thyroid and Its Indispensability in Fertility.” Journal of Human Reproductive Sciences, vol. 4, no. 1, Jan. 2011, pp. 59–60., doi:10.4103/0974-1208.82368.
Kim, C H, et al. “Effect of Levothyroxine Treatment on in Vitro Fertilization and Pregnancy Outcome in Infertile Women with Subclinical Hypothyroidism Undergoing in Vitro Fertilization/Intracytoplasmic Sperm Injection.” Fertility and Sterility, vol. 95, no. 5, Apr. 2011, pp. 1650–1654., doi:10.1016/j.fertnstert.2010.12.004.
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Meczekalski, B, et al. “Functional Hypothalamic Amenorrhea and Its Influence on Women’s Health.” Journal of Endocrinological Investigation, vol. 37, no. 11, Nov. 2014, pp. 1049–1056., doi:10.1007/s40618-014-0169-3.
POI Guideline Development Group. “Guideline on the Management of Premature Ovarian Insufficiency.” European Society of Human Reproduction and Embryology, Dec. 2015, www.eshre.eu/Guidelines-and-Legal/Guidelines/Management-of-premature-ovarian-insufficiency.aspx.
Poppe, K, and D Glinoer. “Thyroid Autoimmunity and Hypothyroidism before and during Pregnancy.” Human Reproduction Update, vol. 9, no. 2, 2003, pp. 149–161., doi:10.1093/humupd/dmg012.
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“Underactive Thyroid (Hypothyroidism) .” NHS, www.nhs.uk/conditions/underactive-thyroid-hypothyroidism/.
Visser, J A, et al. “Anti-Müllerian Hormone: an Ovarian Reserve Marker in Primary Ovarian Insufficiency.” Nature Reviews, Endocrinology, vol. 8, no. 6, 10 Jan. 2012, pp. 331–341., doi:10.1038/nrendo.2011.224.
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I’m Worried my Progesterone Levels are too High
Are high [progesterone](https://nabtahealth.com/glossary/progesterone/) levels causing concern? Understanding the impact of elevated [progesterone](https://nabtahealth.com/glossary/progesterone/) is crucial for maintaining hormonal balance and overall health. [Progesterone](https://nabtahealth.com/glossary/progesterone/) plays a vital part in the menstrual cycle and pregnancy, but when levels rise unreasonably, it can [lead](https://nabtahealth.com/glossary/lead/) to different indications and well-being challenges. This article dives into the signs, causes, and suggestions of tall [progesterone](https://nabtahealth.com/glossary/progesterone/) levels, advertising clear experiences and viable counsel to address this common hormonal issue. Whether experiencing symptoms or seeking preventative measures, powering yourself with knowledge can guide you toward optimal hormonal wellness. You’re not alone in this journey; we’re here to support you. * High [progesterone](https://nabtahealth.com/glossary/progesterone/) symptoms include fatigue, bloating, breast tenderness and [vaginal dryness](https://nabtahealth.com/articles/5-reasons-why-you-may-be-experiencing-vaginal-dryness). * [Progesterone](https://nabtahealth.com/glossary/progesterone/) naturally increases when you become pregnant. * Maintaining [progesterone](https://nabtahealth.com/glossary/progesterone/) at a ‘normal’ level has health benefits, for example it can help boost your mood. * Low [progesterone](https://nabtahealth.com/glossary/progesterone/) levels is one of the characteristics of [anovulation](https://nabtahealth.com/glossary/anovulation/) (lack of [ovulation](https://nabtahealth.com/glossary/ovulation/)), which is a symptom of [PCOS](https://nabtahealth.com/glossary/pcos/). * If your [progesterone](https://nabtahealth.com/glossary/progesterone/) levels are too high and you are not pregnant, some causes can include ovarian cysts, congenital [adrenal hyperplasia](https://nabtahealth.com/glossary/adrenal-hyperplasia/) and ovarian cancer. #### I have high [progesterone](https://nabtahealth.com/glossary/progesterone/) symptoms. 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We support women with their personal health journeys, from everyday wellbeing to the uniquely female experiences of fertility, pregnancy, and [menopause](https://nabtahealth.com/glossary/menopause/). Get in [touch](/cdn-cgi/l/email-protection#334a525f5f52735d525147525b56525f475b1d505c5e) if you have any questions about this article or any aspect of women’s health. We’re here for you. #### **Sources:** Briden, L. “Roadmap to [Progesterone](https://nabtahealth.com/glossary/progesterone/).” _Lara Briden – The Period Revolutionary_, 19 Jan. 2014, [www.larabriden.com/road-map-to-](http://www.larabriden.com/road-map-to-progesterone/)[progesterone](https://nabtahealth.com/glossary/progesterone/)/. Holm, G. “Serum [Progesterone](https://nabtahealth.com/glossary/progesterone/) Test: Purpose, Results, and Risks.” _Healthline_, [www.healthline.com/health/serum-](http://www.healthline.com/health/serum-progesterone)[progesterone](https://nabtahealth.com/glossary/progesterone/). Medically reviewed by University of Illinois-Chicago, College of Medicine on August 22, 2016. “[Progesterone](https://nabtahealth.com/glossary/progesterone/).” _Lab Tests Online_, AACC, [labtestsonline.org/tests/](http://labtestsonline.org/tests/progesterone)[progesterone](https://nabtahealth.com/glossary/progesterone/). This article was last modified on December 28, 2018.
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These symptoms can be treated with antibiotics. * [PCOS](https://nabtahealth.com/glossary/pcos/) cause urinary and bowel issues even when women have non-classic [PCOS](https://nabtahealth.com/glossary/pcos/). * This is because the cysts may press against the bladder and rectum (bowel). * Cysts can be removed under general anaesthetic. * [PCOS](https://nabtahealth.com/glossary/pcos/) symptoms can be relieved through changing your lifestyle. #### Classic and Non-Classic [PCOS](https://nabtahealth.com/glossary/pcos/) Despite its name, polycystic ovary syndrome [](https://nabtahealth.com/do-polycystic-ovaries-equal-pcos/)[does not require the presence of polycystic](https://nabtahealth.com/do-polycystic-ovaries-equal-pcos/) [](https://nabtahealth.com/do-polycystic-ovaries-equal-pcos/)[ovaries](https://nabtahealth.com/glossary/ovaries/). In fact, when present together, excess of male hormones ([hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/)) and lack of [ovulation](https://nabtahealth.com/glossary/ovulation/) ([anovulation](https://nabtahealth.com/glossary/anovulation/)) comprise the [classic form of](https://nabtahealth.com/what-is-pcos/) [PCOS](https://nabtahealth.com/glossary/pcos/), which is more common and generally associated with more severe side effects than the non-classic form. Women who have non-classic [PCOS](https://nabtahealth.com/glossary/pcos/) can have [polycystic](https://en.wikipedia.org/wiki/Polycystic_ovary_syndrome) [ovaries](https://nabtahealth.com/glossary/ovaries/) with regular menstrual cycles and [](https://nabtahealth.com/is-hyperandrogenism-a-symptom-of-pcos/)[hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/) (non-classic ovulatory [PCOS](https://nabtahealth.com/glossary/pcos/)). Or they can have normal [androgens](https://nabtahealth.com/glossary/androgen/) but experience chronic [anovulation](https://nabtahealth.com/glossary/anovulation/) (non-classic mild/normoandrogenic [PCOS](https://nabtahealth.com/glossary/pcos/)). #### [PCOS](https://nabtahealth.com/glossary/pcos/) Can Cause Urinary and Bowel Issues Although non-classic [PCOS](https://nabtahealth.com/glossary/pcos/) is typically milder, those women who have extensive ovarian cysts may experience pain in the pelvic region where the cysts press against the bladder and rectum. Associated symptoms include nausea, urinary conditions, and [constipation](https://nabtahealth.com/glossary/constipation/). Depending on the severity of the symptoms, treatment options range from over-the-counter pain relief medication to cyst removal under general anaesthetic. Ultrasound investigation will be used to establish how invasive the cysts are. In addition to the pain and pressure caused by the presence of cysts in the abdominal region, many women with [PCOS](https://nabtahealth.com/glossary/pcos/) experience symptoms that are usually associated with diabetes. This is probably because a large proportion of women with the condition are insulin resistant. Symptoms such as sugar cravings, frequent urination, blurred vision, delayed healing, and a tingling sensation have all been reported. To date, the most effective way of relieving the symptoms of [PCOS](https://nabtahealth.com/glossary/pcos/) is through the implementation of [lifestyle changes](https://nabtahealth.com/is-it-possible-to-reverse-pcos/), such as weight loss. What are the common urinary and bowel symptoms associated with [PCOS](https://nabtahealth.com/glossary/pcos/)? -------------------------------------------------------------------------------------------------------------- * Polycystic ovary syndrome ([PCOS](https://nabtahealth.com/glossary/pcos/)) is a common hormonal disorder that affects women of reproductive age. * It is caused by a hormonal imbalance in the body and can [lead](https://nabtahealth.com/glossary/lead/) to a number of symptoms, including irregular menstrual periods, excess hair growth, acne, and weight gain. * While urinary and bowel issues are not typically considered common symptoms of [PCOS](https://nabtahealth.com/glossary/pcos/), they can occur in some individuals with the condition. * The most common urinary symptom associated with [PCOS](https://nabtahealth.com/glossary/pcos/) is urinary tract infections (UTIs), which can cause symptoms such as frequent or urgent urination, pain or burning during urination, and cloudy or bloody urine. * Another urinary issue that can occur with [PCOS](https://nabtahealth.com/glossary/pcos/) is incontinence, or the inability to control the release of urine from the bladder. * [Constipation](https://nabtahealth.com/glossary/constipation/) is a common symptom of [PCOS](https://nabtahealth.com/glossary/pcos/). This can be caused by hormonal imbalances and changes in the levels of insulin and other hormones in the body. * It’s important to talk to a doctor if you have [PCOS](https://nabtahealth.com/glossary/pcos/) and are experiencing any symptoms related to your urinary or bowel health. They can help diagnose and treat any underlying issues and provide you with the care and support you need to manage your condition. To read more about factors that are associated with [PCOS](https://nabtahealth.com/glossary/pcos/) click [here](https://nabtahealth.com/treating-the-associated-symptoms-of-pcos/) and consider Nabta’s [](https://nabtahealth.com/product/pcos-test/)[PCOS](https://nabtahealth.com/glossary/pcos/) Test to understand more. Nabta is reshaping women’s healthcare. We support women with their personal health journeys, from everyday wellbeing to the uniquely female experiences of fertility, pregnancy, and [menopause](https://nabtahealth.com/glossary/menopause/). Get in [touch](/cdn-cgi/l/email-protection#81f8e0edede0c1efe0e3f5e0e9e4e0edf5e9afe2eeec) if you have any questions about this article or any aspect of women’s health. We’re here for you. FAQ’s On [PCOS](https://nabtahealth.com/glossary/pcos/) Cause Urinary and Bowel Issues? --------------------------------------------------------------------------------------- ### Can [PCOS](https://nabtahealth.com/glossary/pcos/) Cause Blood In Urine Yes, Polycystic Ovary Syndrome ([PCOS](https://nabtahealth.com/glossary/pcos/)) can indirectly cause blood in urine due to associated conditions like urinary tract infections (UTIs) or kidney issues. It’s important to consult a healthcare provider for an accurate diagnosis and appropriate treatment. ### [PCOS](https://nabtahealth.com/glossary/pcos/) Urine Color [PCOS](https://nabtahealth.com/glossary/pcos/) does not usually change urine color directly. However, related conditions such as UTIs or dehydration can cause urine to appear darker, cloudy, or bloody. Consult a healthcare provider if you notice unusual changes in urine color. Does [PCOS](https://nabtahealth.com/glossary/pcos/) Cause You To Pee a Lot -------------------------------------------------------------------------- Yes, [PCOS](https://nabtahealth.com/glossary/pcos/) can cause you to pee a lot due to related conditions like [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/) or diabetes, which can increase thirst and urination. It’s essential to consult a healthcare provider for proper diagnosis and management. ### Can [PCOS](https://nabtahealth.com/glossary/pcos/) Cause UTI Yes, [PCOS](https://nabtahealth.com/glossary/pcos/) can increase the risk of urinary tract infections (UTIs) due to hormonal imbalances and [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/). It’s important to consult a healthcare provider for proper diagnosis and treatment. ### [PCOS](https://nabtahealth.com/glossary/pcos/) Peeing a Lot Yes, [PCOS](https://nabtahealth.com/glossary/pcos/) can cause frequent urination due to associated conditions like [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/) or diabetes, which can [lead](https://nabtahealth.com/glossary/lead/) to increased thirst and urination. Consult a healthcare provider for proper diagnosis and management. #### **Sources:** El Hayak, S, et al. “Poly Cystic Ovarian Syndrome: An Updated Overview.” _Frontiers in Physiology_, vol. 7, 5 Apr. 2016, p. 124., doi:10.3389/fphys.2016.00124. Norman, R J, et al. “The Role of Lifestyle Modification in Polycystic Ovary Syndrome.” _Trends in Endocrinology and [Metabolism](https://nabtahealth.com/glossary/metabolism/)_, vol. 13, no. 6, Aug. 2002, pp. 251–257. Patel, S. “Polycystic Ovary Syndrome ([PCOS](https://nabtahealth.com/glossary/pcos/)), an Inflammatory, Systemic, Lifestyle Endocrinopathy.” _The Journal of Steroid Biochemistry and Molecular Biology_, vol. 182, Sept. 2018, pp. 27–36., doi:10.1016/j.jsbmb.2018.04.008.