Published in City Times



Ovulation, a Mysterious Phenomenon


Did you know that when a woman is five months into her pregnancy with a baby girl, the baby is already having 2 million eggs inside her ovaries? Or that these eggs decrease continuously over a period of time so that when the baby girl is born, her ovaries contain all the egg cells she will ever possess – about 500, 000 in each of them! And that, every month of her life, a few hundreds of these will disappear as a natural, normal process, so that when she reaches menopause, there are no more eggs left in her ovaries! Well, if nature’s ways are fascinating, they are as much complex and could upset the apple cart at any point of time, reveals Dr.Mohd. Ali Bouhadiba, Specialist Obstetrician and Gynaecologist, Welcare Hospital, Dubai, as he explains the mysterious phenomenon of ovulation.

What is ovulation and what does the process involve?
Dr.Bouhadiba: Ovulation is a process that happens when a girl child attain puberty. This process involves the ripening and release of one of the thousands of egg cells. As the egg develops, there is water accumulation around it and the formation of a small blister like structure called follicle which gradually increases in size as more water accumulates. As the follicle grows in size, the egg also moves from its central position to the surface of the ovary. At mid cycle, the follicle ruptures, releasing the egg, thus completing the process of ovulation, following which, the egg travels to the fallopian tubes to be fertilized. But this process of ovulation which may sound simple, is actually a very complex and complicated process and may not happen at all for various reasons, explains Dr. Bouhadiba. And the commonest cause of female infertility may be lack of ovulation, reveals the doctor.

What are the factors that can prevent ovulation from happening?
Dr. Bouhadiba: There are a number of factors that can inhibit ovulation from taking place. Firstly, the woman’s body weight is an important factor affecting ovulation. Fat can interfere with the hormones produced by the ovaries in different ways. Depending on the amount of fat in the body, the woman can produce weak or strong hormones. The cells of fat themselves produce a protein called Leptine which can block the production of hormones from the ovaries which could interfere with the ovulation process.

Secondly, as a woman advances in age, the egg cells in her ovaries diminish or function poorly because the DNA cells in her eggs could be altered. Both these factors inhibit ovulation or give a poor quality ovulation and result in egg-related infertility in the woman. Various studies reveal that 37 years is the threshold after which fertility could drop sharply in women.

Thirdly, chronic inflammation of the ovaries lead to a condition called unruptured follicle which prevents ovulation from happening. In fact, we may have all the signs of ovulation in the woman – all the necessary hormonal changes may occur, yet ovulation doesn’t take place. This is due to chronic ovarian inflammation which itself may be the result of chronic infection or endometriosis, a condition in which few cells from the lining of the womb come out through the Fallopian tubes, into the abdomen where they start growing and cause the inflammation.

Fourthly, everything may be normal with the woman’s ovaries and cells, hormones, no inflammation, yet ovulation doesn’t occur. This may result from the woman’s ovaries not responding to stimulation by the hormones. This is because, for the hormones to work, they need a receptor. And the woman’s ovaries may lack these receptors or have poorly functioning receptors, due to which they cannot ovulate.

Fifthly, some women suffer from a condition called Polycystic Ovarian Disease or Syndrome (PCOD or PCOS) in which the ovaries get enlarged and their small microcysts gather at the surface of the ovary as the outer surface is covered by a thick shell. In PCOS, these follicles remain immature and fail to develop or ovulate to produce an egg capable of being fertilised.

So how is the problem dealt with? Are these conditions treatable?
Dr.Bouhadiba: Yes, almost all of these are generally amenable to treatment though they may require specialist intervention beyond primary care. As I mentioned the instance of lack of receptors hindering ovulation, treating this condition is a bit more complicated than the other causes. But recent studies have shown that cell maturation can take place outside of the women’s body, in a laboratory under controlled conditions. And this technique is increasingly being used to treat women with infertility since it is better, safer, more cost effective and avoids the use of all the excess over-reaction of the body to drugs given in the conventional infertility treatment.

How exactly does this cell maturation take place outside the woman’s body?
Dr.Bouhadiba: The procedure is done under general anesthesia. The woman’s ovaries are punctured and some egg cells removed. When we remove the egg, it is an immature cell. The cells are matured and fertilized in the laboratory – a process that takes about three to four days. Once the eggs are fertilized, they are implanted in the woman’s womb.

How are the women with PCOD treated?
Dr.Bouhadiba: Recent studies have found a strong correlation between PCOD and insulin resistance. That is, many of these women who have PCOD, also have raised resistance to insulin; which means they have mild diabetes. So the present trend has been to treat these women with Metformin, an anti-diabetic drug, which has also been found useful in bringing down not only sugar levels, but also help in reduce body weight, reduce cholesterol and triglycerides and enable the ovaries to function better. In fact, the trend has been to go one step further and give Metformin to girls as young as 8 years old, who are on the plump side and who show a tendency to insulin resistance. Because these girls, should they be prone to PCOD in the future, will not develop the condition if they are started on Metformin, early.

Would this imply that every plump girl should be given Metformin?
Dr.Bouhadiba: Yes, every one of them who we suspect is insulin-resistant and is tested positive.

So are there any symptoms to reveal that the girl may be insulin-resistant?
Dr.Bouhadiba: No. Except their being a little fat.

But many children these days tend to be fat or overweight because of the general lifestyle. So do you mean to say that every fat child of 8 years and above, who might have a BMI (Body Mass Index) of 25 or more, should be tested for insulin resistance?
Dr.Bouhadiba: Yes, ideally so. However, this is not being done at present but trends definitely point towards such a screening process because it is better for the health of the girl in future. However, this does not mean that every plump girl will be insulin resistance and/or will go on to develop PCOD.

If a child of 8 is begun on Metformin, for what period of time will she have to continue taking it? What are its long term side effects?
Dr.Bouhadiba: This aspect of the study is still going on and as yet no conclusions can be drawn on it. As of now, metformin given to adult women with symptoms of PCOD have shown improvement without any adverse effects which may be cause of concern.


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