unexplained > Male factors > Endometriosis > Tubal factors. Treatment of anovulation is determined by the diagnosis : An elevated FSH along with chronic anovulation indicates ovarian resistance or failure : treatment is steroids / in vitro feilisation in such cases. If chronic anovulation is present along with normal FSH and prolactin : then induction of ovulation can be achieved in 90% of cases. - A treatment plan is done using clomiphene as the first drug : 1. Colmiphene citrate : it is the agent of choice for women with oligomenorrhea or amenorrhea having sufficient ovarian function to maintain estrogen at a serum level of 40pg/ml. Patient selection Normal gonadotropicdeg : normoprolactinemicdeg patients with normal cycle but absent or infrequent ovulation.deg PCOSdeg Post pill amenorrhea.deg Dose Initial dose of 25 to 50mgdeg is given daily from 02 - D 5. Ovulation is expected to occur about 5 - 7 days after the last day of therapy. If ovulation doesnot occur, dose is increased in 50mg steps to a maximum of 250mg daily. Therapy is in given for 4-6 cycles. Clomiphene will be successful in inducing ovulation in about 70% of women, with ovaries producing estrogen. Switch over from clomiphene to more aggressive therapy is done when : There is no response to clomiphenedeg There is ovulatory response to clomiphene but no pregnancy.deg Patients with pituitary insufficiency.deg These patients usually respond to Gonadotropins. 2. Gonadotropin therapy : Prerequisite for Gonadotropin therapy : Ovarian reserve must be present. The Gonadotropins used are : Human menopausal Gonodotropin : - It is a formulation containing equal amounts of FSH and LH (751U each). - It is prepared from hormones obtained from urine of postmenopausal women. - HCG is required as an ovulatory trigger. - FSH : purified urinary FSH and Recombinant FSH are also available. 3. Gonadotropin releasing hormone : Pulsatile GnRH If other methods have failed then pulsatile GnRH is needed in patients with anovulation and hypothalamic insufficiency Other drugs which can be used to for ovulation : 1. Bromocriptine/Cabergoline : Are used to to treat anovulation caused by increase in serum prolactin level. 2. Coicosteroids : Use to treat anovulation due to congenital adrenal hyperplasia. Tamoxifen : It is an antiestrogen. It is an alternative to clomiphene and is used for the same type of cases. Metformin and letrozole : Used to treat infeility due to hyper insulinemia and insulin resistance.">