Editing Anovulation (section)

===Treatment for polycystic ovarian syndrome (PCOS)===
{{Further|Infertility in polycystic ovary syndrome}}
Treatment for management of anovulation due to PCOS is multifaceted, including weight reduction, ovulation induction agents, insulin-sensitizing agents, gonadotrophins and ovarian drilling. In PCOS patients with overweight or obesity, weight loss is first line treatment. Studies show a reduction in weight as little of 5% by caloric restriction and increased physical activity can re-establish spontaneously ovulation and improve response to ovulation induction therapy if initiated.<ref>{{Cite journal|date=2008-03-01|title=Consensus on infertility treatment related to polycystic ovary syndrome|journal=Human Reproduction|volume=23|issue=3|pages=462–477|doi=10.1093/humrep/dem426|pmid=18308833|issn=0268-1161|author1=Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group|doi-access=}}</ref><ref>{{Cite journal|last1=Moran|first1=Lisa J.|last2=Pasquali|first2=Renato|last3=Teede|first3=Helena J.|last4=Hoeger|first4=Kathleen M.|last5=Norman|first5=Robert J.|date=2009|title=Treatment of obesity in polycystic ovary syndrome: a position statement of the Androgen Excess and Polycystic Ovary Syndrome Society|journal=Fertility and Sterility|volume=92|issue=6|pages=1966–1982|doi=10.1016/j.fertnstert.2008.09.018|pmid=19062007|issn=0015-0282|doi-access=free}}</ref> [[Weight loss]] also generally results in improved menstrual regularity and pregnancy rates in women with PCOS.<ref name="Hamilton-Fairley2003">{{cite journal|last1=Hamilton-Fairley|first1=D.|title=Anovulation|journal=BMJ|volume=327|issue=7414|year=2003|pages=546–549|issn=0959-8138|doi=10.1136/bmj.327.7414.546|pmid=12958117|pmc=192851}}</ref>

It is well recognized that insulin resistance can be part of the sequelae of PCOS and if present, contribute to anovulation. Metformin, a biguanide, is a common insulin sensitizer often given to treat women with PCOS.<ref name=":6" /> No other insulin sensitizers have evidence of effective and safe use of fertility treatment.<ref name=":6" /> Previously, [[metformin]] was recommended as treatment for [[anovulation in polycystic ovary syndrome]], but in the largest trial to date, comparing clomiphene with metformin, clomiphene was more effective than metformin alone.<ref name=":2" /> Following this study, the ESHRE/ASRM-sponsored A consensus workshop does not recommend metformin for ovulation stimulation.<ref name="pmid18243179">{{cite journal|author=Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group|date=March 2008|title=Consensus on infertility treatment related to polycystic ovary syndrome|journal=Fertil. Steril.|volume=89|issue=3|pages=505–522|doi=10.1016/j.fertnstert.2007.09.041|pmid=18243179}}</ref> Subsequent randomized studies have confirmed the lack of evidence for adding metformin to clomiphene.<ref>{{cite journal|author=Johnson NP|author2=Stewart AW|author3=Falkiner J|last4=Farquhar|first4=C. M.|last5=Milsom|first5=S.|last6=Singh|first6=V.- P.|last7=Okonkwo|first7=Q. L.|last8=Buckingham|first8=K. L.|last9=React-Nz (Reproduction And Collaborative Trials In New Zealand)|first9=a Multi-Centre Fertility Trials Group|display-authors=3|name-list-style=vanc|date=April 2010|title=PCOSMIC: a multi-centre randomized trial in women with PolyCystic Ovary Syndrome evaluating Metformin for Infertility with Clomiphene|journal=Hum Reprod|volume=25|issue=7|pages=1675–1683|doi=10.1093/humrep/deq100|pmid=20435692|doi-access=}}</ref>

==== Ovulation induction ====
{{Main|Ovulation induction}}
The main [[ovulation induction]] medications include:
*[[Antiestrogen]], causing an inhibition of the [[negative feedback]] of estrogen on the [[pituitary gland]], resulting in an increase in secretion of [[follicle-stimulating hormone]]. Medications in use for this effect are mainly [[clomifene citrate]] and [[tamoxifen]] (both being [[selective estrogen-receptor modulator]]s), as well as [[letrozole]] (an [[aromatase inhibitor]]).<ref name=":6" />
*[[Follicle-stimulating hormone]] (FSH), directly stimulating the ovaries. In women with anovulation, it may be an alternative after 7–12 attempted cycles of pituitary feedback regimens (as evidenced by clomifene citrate), since the latter ones are less expensive and more easy to control.<ref name="WeissBraam2014">{{cite journal|last1=Weiss|first1=N. S.|last2=Braam|first2=S.|last3=Konig|first3=T. E.|last4=Hendriks|first4=M. L.|last5=Hamilton|first5=C. J.|last6=Smeenk|first6=J. M. J.|last7=Koks|first7=C. A. M.|last8=Kaaijk|first8=E. M.|last9=Hompes|first9=P. G. A.|last10=Lambalk|first10=C. B.|last11=van der Veen|first11=F.|last12=Mol|first12=B. W. J.|last13=van Wely|first13=M.|title=How long should we continue clomiphene citrate in anovulatory women?|journal=Human Reproduction|volume=29|issue=11|year=2014|pages=2482–2486|issn=0268-1161|doi=10.1093/humrep/deu215|pmid=25164024|doi-access=free}}</ref>