Dr Eric Daiter has successfully served thousands of patients with ovulation problems over the past 20 years. If you have questions, or you are simply not getting the care that you need, Dr Eric Daiter would like to help you at his office in Edison, New Jersey or over the telephone. It is easy, just call us at 908 226 0250 to set up an appointment (leave a message with your name and number if we are unable to get to the phone and someone will call you back).
"I always try to be available for my patients since I do understand the pain and frustration associated with reproductive problems or endometriosis."
"I understand that the economy is very tough and insurance companies do not cover a lot of the services that might help you. I always try to minimize your out of pocket cost while encouraging the most successful and effective treatments available."
Need help or have a question?
What should the ovulation clinical evaluation include?
When an apparent abnormality in ovulation is detected, an organized and cost effective plan of evaluation should be recommended.
(1) A detailed menstrual history should be taken, including
The relative amount (spotting, light, moderate, heavy) and timing of flow (a menstrual diary over several months provides a good amount of information)
Changes in amount or duration of flow. Most studies report that women do not usually have an accurate idea of the actual volume of their flow but that women do know relatively precisely when their flow volume changes
Age at menarche (the initial menstrual flow) and the regularity of the menstrual intervals from menarche to date
Results of administration of any hormonal medication (oral contraceptive pills to regulate the menstrual intervals, progesterone to bring on a flow)
History of pregnancy and the outcome
(2) A detailed medical history should be taken, including
Pelvic surgery especially those involving the ovaries or reproductive organs
Cancer and any treatment with radiation or chemotherapy. Available medical reports describing exactly which areas have been irradiated (and the doses) or which chemotherapeutic agents were used (with cumulative doses) are important
Pelvic inflammatory disease or pelvic infection, especially if involving a pelvic abscess. Medical reports describing the treatment with antibiotics and the woman’s response to treatment (as well as any radiologic or other studies gathered) can be important
Cigarette, alcohol or illicit drug abuse. The amount of use and timing with respect to the onset of the ovulatory dysfunction should be discussed
Endometriosis (including operative reports describing the location and depth of lesions)
Symptoms of decreased estrogen, including hot flashes, tightening of the skin, insomnia, and fatigue
Symptoms of hypothyroidism or hyperthyroidism, including cold or heat intolerance, tremor, palpitations, fatigue, change in bowel habits
Galactorrhea (milky discharge from the breasts) or any source for chronic breast stimulation (such as a thoracotomy or breast surgical scar)
Neurologic symptoms including headaches, blurry or double vision, dizziness, focal weakness.
History of severe (life threatening) hypotension either immediately postpartum or otherwise
Stressful or catastrophic personal events around the onset of the ovulatory problem
Exercise regimen (if serious or elite athlete)
Weight loss history, with height and weight measurements
Male pattern hair growth, acne or oily skin, obesity, history of pelvic ultrasounds with multiple cysts within the ovaries
(3) A physical exam should be performed including an examination of
The skin for acne, excess oiliness, male pattern hair growth, irregular dark velvety discoloration (acanthosis nigricans), stretch marks from prior obesity or prior surgical scars in the abdomen or around the breasts
The breasts for milky discharge (galactorrhea) or surgical scars
The abdomen and pelvis for masses or tenderness
The overall appearance of either Cushing’s syndrome, acromegaly, or anorexia nervosa
(4) An initial laboratory evaluation may appropriately include
Review of documentation aimed at detecting ovulation
A pregnancy test (the number 1 reason for secondary amenorrhea in reproductive age women)
Blood concentration of TSH and prolactin even if the patient is asymptomatic, with appropriate followup if abnormal
Blood concentration of FSH, LH and estradiol (on cycle day 3 if woman has a cycle) if there is a suspicion of ovarian failure, hypothalamic or pituitary dysfunction (stress, exercise, weight loss, weight extreme) or polycystic ovaries, with appropriate followup if abnormal
Evaluation for Cushing’s syndrome (either 24 hour urine for "urine free cortisol" or overnight 1 mg Dexamethasone suppression test with 8 A.M. blood cortisol concentration) if clinical appearance is suggestive
Evaluation for acromegaly (either blood growth hormone concentration [both fasting and during an oral glucose tolerance test] or an IGF-1 concentration) if clinical appearance is suggestive
In some situations, radiologic testing of the brain will be recommended. The best radiologic exam is not always the most cost effective one, and there is a continuing debate among physicians concerning the most appropriate screening test to radiologically examine the pituitary region of the brain. MRI with gadolinium contrast, CT with contrast, or lateral coned down x-ray views of the sella turcica are frequently performed. In general, the MRI gives the best detail and resolution (best picture) and the x-ray is the least expensive with the least resolution (but adequate to see tumors that are greater than 1 cm in size).
For some women, a progesterone challenge test (after confirming that the patient is not pregnant) will be recommended. This test determines whether there is adequate estrogen production by the ovaries to achieve growth of the endometrial lining of the uterus. Medroxyprogesterone acetate (provera, 5-10 mg by mouth per day for 5-10 days), micronized progesterone (100-200 mg by mouth two to three times per day for 5-10 days), progesterone vaginal suppositories (50-200 mg per vagina two to three times per day for 5-10 days), progesterone in oil (either sesame oil or peanut oil, 150-200 mg intramuscular injection once) are alternative appropriate progesterone compounds. The natural compounds (all but provera) are safest if treatment (rather than testing) is to be continued regularly (such as monthly) and the woman is simultaneously trying to get pregnant.
A withdrawal flow is expected a few days after the final progesterone dose (or within 2 weeks of the injection). Uncommonly, the progesterone taken may allow the woman to have a spontaneous (natural) ovulation. If a spontaneous ovulation occurs the natural progesterone produced from the resulting corpus luteum cyst will delay the withdrawal flow for up to an additional 2 weeks. Therefore, you must wait at least 2 weeks from the time of expected flow to see whether a natural ovulation has occurred. The reason for an occasional spontaneous ovulation is that small amounts of progesterone decrease the threshold for ovulation (makes ovulation easier).
The results of this initial evaluation will provide a tremendous amount of information and the physician will most likely be able to readily advise a couple on the likely cause(s) for the ovulatory dysfunction. Additional confirmatory testing will sometimes be required. The available treatment options for these ovulatory dysfunctions depend on the cause of the dysfunction and the goals of the woman involved.