Treatment of ovulatory dysfunction

Referral to Infertility Specialist.

If hpogonadotropic hypogonadism (1)

• women, and trans men and non-binary people with female reproductive organs who have hypogonadotropic hypogonadism and anovulatory infertility should be advised that they may improve their chance of regular ovulation, conception and an uncomplicated pregnancy by:
  • increasing their body weight to reach a healthy weight if they have a body mass index (BMI) of less than 18.5 kg/m2 and/or
  • moderating their exercise levels if they undertake high levels of exercise
• gonadotrophins with luteinising hormone activity or gonadotrophin releasing hormone should be offered to induce ovulation in women, and trans men and non-binary people with female reproductive organs who have hypogonadotropic hypogonadism

If ovulatory disorders due to hyperprolactinaemia (1)

• cabergoline should be offered to treat ovulatory disorders due to hyperprolactinaemia

If hypothalamic-pituitary-ovarian dysfunction (predominantly PCOS)

• a review (2) states that in women with PCOS undergoing ovulation induction, letrozole is the first-line therapy and results in higher live birth rates compared with clomiphene

Notes:

• clomiphene citrate is a selective estrogen receptor modifier that blocks the negative feedback effect of circulating estradiol and causes an increased hypothalamic gonadotropin-releasing hormone (GnRH) pulse frequency and subsequent pituitary FSH and luteinizing hormone (LH) production, promoting ovarian follicular growth
• letrozole blocks aromatase, reducing serum concentrations of estradiol and stimulating pituitary gonadotropins
• both clomiphene citrate and aromatase inhibitors have a multiple pregnancy rate of less than 10%, the majority of which are twin gestations

Reference:

1. NICE. Fertility problems: assessment and treatment. Clinical guideline CG156. Published February 2013, last updated March 2026
2. Carson SA, Kallen AN; Diagnosis and Management of Infertility: A Review. JAMA. 2021 Jul 6;326(1):65-76.