Prevalence of Anovulation in Subfertile Women in Kerbala 2012, A descriptive Cross-Sectional Study Mousa Mohsen Ali* Wasan Ghazi* HayderAamerAbboud^ *Kerbala University, College of Medicine, Gynecology Department, ^College of Medicine, Physiology Department Letters for correspondence: dr_mousaobgyn@yahoo.com, dr.hayderaamer@yahoo.com. Abstract Ovulation is the result of a maturation process that occurs in the hypothalamic-pituitaryovarian (HPO) axis and is orchestrated by a neuroendocrine cascade terminating in the ovaries. Any alteration results in a failure to release a mature ovum, leading to anovulatory cycles. Anovulation may manifest in a variety of clinical presentations, from luteal insufficiency to oligomenorrhea. Anovulation is not a disease but a sign, in much the same way that polycystic ovaries are the manifestation of a much larger disease process. Purpose of Study: The purpose of study was to find the prevalence of anovulation amongst subfertile women consulting infertility outpatient clinic in Karbala Maternity Hospital and we aim to assess the information found in patient clinical data files and the commitment of hospital to follow proper method to diagnosed the infertility and its causes. Materials and Methods:Location and time of study:karbala Maternity Hospital from1 st of January 2012-1 st of January 2013.This is a retrospective study sampling the subfertile women consulting infertility outpatient clinic in Karbala Maternity Hospital during 2012. The Sample of study was 426 patients their files had been studied expeditiously exploring their investigations and follow-up. We took many information like age, type of infertility, occupation, ultrasonic features, Hysterosalpingography, and hormonal assays if available. There are many criteria that can be relied on to confirm anovulation however we revert for ultrasonic ones because other criteria were either missing or not well documented to depend on. Data Analysis was made by SPSS Program Version 16 and Chi square for the results obtained. Results and Discussion: The mean age of sample is 26.42 (SD 7.218) and most of the study population was house wives constituting about 91.3%. Ultrasonically confirmed anovulation constitutes about 58.1%, Confidence interval was 4.5% with confidence level of 95%. However, clinical data were missing for most of the patients.dual Factors for infertility like anovulation and uterine abnormality constitutes 0.2%. Conclusion and Recommendations:Anovulatory infertility is by far the most common cause in both primary and secondary infertility in Karbala.Hormonal Assays are by far enormously important in investigating subfertile women; however they should be labeled at which time of the cycle they have been taken because interpretation differs and without labeling it makes revising the patient investigations useless and also complicates research issues.clinical data in patient files were very primitive if present at all and this should be changed in future because there were clinical criteria for many disorders like Polycystic ovarian syndrome. Keywords: Anovulation, Subfertile women, Karbala, Iraq. Introduction Infertility is typically defined as the inability to achieve pregnancy after one year of unprotected intercourse. If the couple has been trying to conceive for a year or more, they should consider an infertility evaluation. However, if they are 35 years or older, it should begin the infertility evaluation after about six months. (American society 2012) 1
As a woman's age increases, the incidence of infertility also increases (Campbell. Monga, 2006). Infertility should be differentiated from fecundability, which is the probability of achieving a pregnancy each month, and fecundity, which is the ability to achieve a live birth within 1 menstrual cycle. The fecundability rate in the general reproductive-aged population is fairly constant and is approximately 0.22 per month (Maruani, Schwartz. 1983). The estimated fecundity rate is 0.15-0.18 per month, representing a cumulative pregnancy rate of 90% per year (Trussell, Wilson. 1985). Infertility is caused by male and/or female factors. Male and female factors each account for approximately 35% of cases. Often, there is more than one factor, with male and female factors combined causing 20% of infertility. In the remaining 10% of cases, the etiology is unknown. Female factor infertility can be divided into several categories: cervical or uterine, ovarian, tubal, and other(matthiesen et al, 2011) Ovulatory dysfunction is defined as an alteration in the frequency and duration of the menstrual cycle. A normal menstrual cycle lasts 25-35 days, with an average of 28 days. Failure to ovulate is the most common infertility problem. Absence of ovulation can be associated with primary amenorrhea, secondary amenorrhea, or oligomenorrhea. It is the cause of infertility in about 15 20% of women seeking treatment for subfertility (Templeton A., 2000) and polycystic ovary syndrome accounts for 90% of such cases (Balen AH, Michelmore K. 2002) At the other end of the body weight spectrum, women who are underweight as a result of illness, anorexia nervosa, or over exercise also become amenorrhoeic. In this situation, lack of the endocrine messenger leptin, which is secreted from fat, prevents pulses of gonadotrophin releasing hormone being released from the hypothalamus (Adam and Anthony 2007) Ovulation is the result of a maturation process that occurs in the hypothalamic-pituitaryovarian (HPO) axis and is orchestrated by a neuroendocrine cascade terminating in the ovaries. Any alteration results in a failure to release a mature ovum, leading to anovulatory cycles. Anovulation may manifest in a variety of clinical presentations, from luteal insufficiency to oligomenorrhea. Anovulation is a not a disease but a sign, in much the same way that polycystic ovaries are the manifestation of a much larger disease process. Many have been written on the different clinical entities associated with anovulation. Based on serum gonadotropins and ovarian hormones, clinicians are usually able to discern whether the ovulatory dysfunction is of central or ovarian origin (McGraw Hill; 2008). In the presence of PCOS, hormone levels are usually within the reference range, but they are accompanied by a wide array of clinical manifestations that may signal the presence of this disorder. Ovarian factors for infertility accounted for about 50.6% of all cases in one Iraqi study conducted before our study. In primary and secondary infertility Ovarian factors constitutes 53.6% and 43.6% of causes respectively (Nuha.et.al, 2007 ( Polycystic ovary syndrome diagnosis depends on any two of the followings (The Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group): Clinical and/or biochemical signs of hyperandrogenism and exclusion of other etiologies (eg, congenital adrenal hyperplasia [CAH], androgen-secreting tumors, Cushing syndrome) Oligo-ovulation or anovulation Polycystic ovaries - Presence of 12 or more follicles in each ovary measuring 2-9 mm in diameter and/or increased ovarian volume greater than 10 mm 3 (Campbell. Monga, 2006, The Rotterdam 2004) 2
Chronic anovulation: Chronic anovulation with estrogen present can occur in a variety of endocrine disorders. Premature ovarian failure: Premature ovarian failure (POF), also known as hypergonadotropic hypogonadism, occurs when oocytes and the surrounding cells are lost prior to 40 years of age (Andrew 2010, Melanie 2012). The purpose of study was to find the prevalence of anovulation amongst subfertile women consulting infertility outpatient clinic in Karbala Maternity Hospital and we aim to assess the information found in patient clinical data files and the commitment of hospital to follow proper method to diagnosed the infertility and its causes. Materials and Methods Location and time of study : Karbala Maternity Hospital from1 st of January 2012-1 st of January 2013. This is a retrospective study sampling the subfertile women consulting infertility outpatient clinic in Karbala Maternity Hospital during 2012. The sample of study was 426 patients their files had been studied expeditiously exploring their investigations and follow-up. We take many information like age, type of infertility, occupation, ultrasonic features, Hysterosalpingography, and hormonal assays if available. Data Analysis was made by SPSS Program Version 16 and Chi square for the results obtained. There are many criteria that can be relied on to confirm anovulation however we revert for ultrasonic ones because other criteria were either missing or not well documented to depend on. Ultrasonically confirmed anovulation includes: (Bilateral Polycystic Ovarian Changes, Non Mature Follicle after ovarian stimulation, and Multiple Follicular Cysts). We can rely on hormonal assays as most of them were carried in the early follicular phase, However clinical data were missing for most of the patients. 3
Results Table (1): Demographic Data and Infertility Type. Age distribution Frequency Valid Percent 16-20 109 24.33 21-25 129 29.9 26-30 78 18.0 31-35 62 14.5 36-40 36 8.2 41-45 16 3.7 Total 426 100.0 Occupation House Wife 389 91.3 Worker 2.5 Student 3.7 Teacher 12 2.8 Doctor 2 0.5 Employer 9 2.1 Paramedical 9 2.1 staff(nurse) Total 426 100.0 Type of Infertility Primary Infertility 278 65.3 Secondary Infertility 148 34.7 Total 426 100.0 Table(2): Hormonal Assays and its percentage regarding the level FSH (IU/ml) (IU/ml) Frequency Valid Percent 0.1-10 77 81.9 11-15 8 8.5 16-20 5 5.3 21 and higher 4 4.3 Total 94 100.0 4
Not done 336 Total 430 FrequencyLH(IU/ml) Valid Percent 0.1-10 Normal 80 77 84.2 18.2 Unilateral Polycystic 11-15 Ovarian 9 1 9.5.2 Changes Bilateral Polycystic Ovarian 16-20 Changes 2 82 2.1 19.4 Simple 21 and Ovarian highercyst 4 5 4.2 1.2 Small Total Ovaries 95 2 100.0.5 Non Mature Not done Follicle 335 163 38.5 Fibroid 4.9 No Ultrasound Total 430 82 19.4 Uterine Abnormality 0.1-10 80 2 84.2.5 Surgically Removed Single Ovary PRL(IU/ml) 1.2 Multiple Follicular 0.1-30 Cysts 111 1 89.5.2 Non Mature Follicle and Uterine 1.2 31 and Abnormality higher 13 10.5 Unilateral Small Ovary Total with 124 1 100.0.2 Surgically Removed Not other done Ovary 306 Total Total 430 423 100.0 Table (3): Ultrasonic Features in the groups of selected women and the different types of radiological abnormalities; The mean age of sample is 26.42yr (SD 7.218). Most of the study population was house wives constituting about 91.3%, others including Teacher 2.8%, Nurse 2.1%, Employee 2.1%, Doctor 0.5%, Student 0.7% and Free Workers 0.5%. Percentage of Primary Infertility was 65.3% and Secondary Infertility 34.7%. as shown in table (1). 5
Unfortunately only 113 out of 430 patients had been subjected for FSH measurement as shown in table (2). And only 112 out of 430 patients had been sent for LH measurement as shown in table( 2) and only 125 out of 430 patients had been subjected for PRL measurement as shown in table (2). Ultrasonically confirmed anovulation constitutes about 58.1%. Dual Factors for infertility like anovulation and uterine abnormality constitutes 0.2%. Confidence interval was 4.5% with confidence level of 95% as shown in Table (3) Discussion: The prevalence of anovulation in one previous study of Nuha.et.al was only 20.3% of the total cases as compared to 58.1% in our study which indicates the need for further study including larger population and more number of women with infertility to have more accurate incidence. Uterine factors accounted for 1.4% of causes in our study compared with 8.1% in the Iraqi study conducted before. Tubal factors were not accurately investigated in our study because Hysterosalpingography were done in few patients and was normal in the majority whereas being the second commonest cause accounting for about 23.1% of causes of infertility in the Iraqi study conducted before.(nuha.et.al, 2007) From all of the above, we concluded that anovulatory infertility is by far the most common cause in both primary and secondary infertility in Karbala.Ultrasound reports should be labeled at which time of the cycle has been obtained and whether the patient was on ovulation stimulating drugs or not, this is because we have faced many files without such information.hormonal Assays are by far enormously important in investigating subfertile women; however they should be labeled at which time of the cycle they have been taken because interpretation differs and without labeling it makes revising the patient investigations useless and also complicates research issues.clinical data in patient files are very primitive if present at all and this should be changed in future because there were clinical criteria for many disorders like PCOS.Documentation should be computerized for purpose of easiness and satisfactoriness as files are very large in number.there is no special form for patients clinical data file in the hospital so we encourage hospital administration to initiate this uniform data file and lastly There is no regular system for follow-up to these files 6
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