Chronic ovulatory disorders are a major cause of infertility, together with tubal disease and male factor problems. It holds therefore that women with chronic anovulation are likely to present with infertility. Appropriate investigations will define various subgroups of patients with chronic anovulation. Ovulation induction will be appropriate in most cases, specifically tailored to individual requirements within these subgroups. Other barriers to conception may co-exist, and it is important that both partners be seen and assessed as part of the infertility work-up.

Diagnosis of anovulation

The diagnosis of chronic anovulation requires an assessment of ovulation as well as establishing the likely cause of anovulation. Historically, ovulatory symptoms include regular (21–35–day) menstrual cycles with Mittelschmirz pain at midcycle, awareness of cervical mucus changes through the cycle, classically described as runny ‘egg-white’ mucus at ovulation and becoming thicker and opaque in the second half of the cycle. In women thought not to be ovulating, pointers to causes of anovulation may include menopausal symptoms in those with ovarian failure, weight loss/stress in hypothalamic dysfunction, obesity, hirsutism in polycystic ovarian disease, and in hyperprolactinaemia/galactorrhoea, visual disturbances, headache and drug ingestion.

Physical examination is often non-contributory for cause, although it does afford the opportunity to assess the breasts and perform a pelvic examination, including a pap smear – important in women planning pregnancy. The body mass index should be determined. Obese women are more resistant to treatment and obesity is a significant risk factor for pregnancy.