Polycyctic ovary syndroms (PCOS)

                       Polycyctic Ovary Syndrome (P.C.O.S.)

 

Polycystic ovary syndrome, a hormonal disorder, can lead to weight gain, acne, and irregular periods. With its holistic healing ways, yoga can be great in treating P.C.O.S.

At the age of sixteen Angha  now thirty five noticed that she was rapidly gaining weight which despite of her efforts seemed impossible for her to lose. Coupled with a irregular menstrual cycle and early signs of excess hair growth on her face, she went to a local general practitioner who diagnosed her with Polycyctic ovarian syndrome or PCOS. It is a health problem that affects on in every ten women of the child bearing age. There,s nothing unwomenly than having to shave your facial hair.

PCOS is a hormonal disorder causing enlarged ovaries with small cyst on the outer edges. Its signs and symptoms are more severe if the women is obese. Its symptoms may begin shortly after puberty, but can also devolop during later teen years and early adulthood.

Introduction
What is P.C.O.S ? It is defines as a health condition which causes hormonal imbalance and metabolism problem in a woman that may affect their overall health and appearance. It causes irregular periods  or prolonged menstrual periods as ovary do not release eggs or ovulate regularly. The condition also releases high level of male hormones in the body, which may result in excess facial or body hair. It also makes them harder to get pregnant. The ovaries may develop numerous small collections of fluid (follicles) and fail to regularly release eggs

P.C.O.S is due to imbalance of reproductive hormone causing enlarged ovaries  with small cysts on the outer edge. P.C.O.S is reversible by making small changes in diet and lifestyle.

Polycystic ovaries. Your ovaries might be enlarged and contain follicles that surround the eggs. As a result, the ovaries might fail to function regularly. In PCOS, instead of a follicle maturing and getting released to be fertilized for pregnancy, the follicle never fully matures and sometimes doesn’t get released from the ovary. Tiny follicles sometimes surround the ovary appearing as a string of pearls on an ultrasound.

Women get affected by PCOS during their child bearing years (15-45 years approximately). Its a hormonal disorder, which affects a woman's ovaries and reproductive hormones get out of balance, due to which women may have infrequent or prolonged menstrual  periods or excess male hormone (androgen) levels

Women with PCOS have insulin resistence. (the body does not use insulin well) resulting in too much insulin in the body. Making dietary changes can improve  insulin sensitivity and reduce insulin resistance. 

When to see your doctor ? if you have concerns about your menstrual periods, if you're experiencing infertility or if you have signs of excess androgen such as worsening hirsutism, acne and male-pattern baldness. The main treatment approach is  managing nutrition intake and making lifestyle changes.Maintaining healthy blood sugar and insulin levels are essential to managing P.C.O.S. Processed and refined food  can disrupt hormonal balance.So clean eating is a way forward to tackle this condition

                                    "Relaxation is the key in treating this disorder."

Cause
●  Combination of genetic and environmental factors.

●  Being sedentary 
●  Eating  unhealthy diet
●  Hormonal imbalance. 65 to 85 % suffer from vitamin D deficiency
●  Heredity  Certain genes might be linked to PCOS.
●  Insulin excess Insulin is a hormone which is produced in pancreas, it allows cells to use sugar, your body,sprimary energy supply. If your body becomes resistant to the action of insulin, than your blood sugar levels can rise and your body might produce more insulin. Excess insulin might increase androgen production, causing difficulty in ovulation.
●  Low grade inflammation This term is used to describe white blood cells' production of substances to fight infection. Research has shown that women with PCOS have a type of low-grade inflammation that stimulates polycystic ovaries to produce androgens, which can lead to heart and blood vessel problems.
●  Excess Androgens The ovaries produce abnormally high levels of androgen, resulting in hirsutism and acne.

                                           "Consult reproductive endocrinologist."                            
  Sign & Symptoms
                             

●  Fatigue

●  Irregular and missed Periods.
●  Irregular or no ovulation is caused by an imbalance of sex hormones, including high levels of testosterone and luteinizing hormone. As a result, some women with PCOS will have a period several times each month, every few months, or not at all. Periods can oftentimes be heavy and accompanied by large clots.  Basically, if a woman has eight or fewer menstrual cycle, per year, she meets the criteria.

●  Excess body hair

●  Acne

●  Oily skin

● Weight gain especially around the belly.

●  Painful periods  Dysmenorrea 
●   Signs of high androgens or testosterone :  Abnormal hair growth (specifically on the face, lower abdomen, back, and chest),acne, skin tax,  male pattern baldness (if applicable), and acanthosis nigricans (darkened thick skin on the neck, thighs, armpits, or vulva).                       
● Hirsutism a term for excess hair growth in women, is common in PCOS women. Hirsutism is a result of higher androgen levels, such as testosterone. Typically, there is increased hair growth in the central part of the body (chest, face, back, lower abdomen, fingers, toes). Some women may experience little to no hair growth at all in these areas, while some women may have a full grown beard.
●  Oily skin or Acne  : Acne may be one of the earliest signs of PCOS in adolescent. It appears on areas like the face, chest, and upper back.
                         

●   Weight gain  :  Gradual or rapid weight gain with no overt reason can indicate P.C.O.S. 
●   Male pattern baldness  :  Hair on the scalp gets thinner and fall out.
                                               

                                            

●   Dry itchy skin  :  Many women also report having dry skin and dandruff from their PCOS as well.The wintertime is a tough time of year for our skin — the cold air can be extremely drying and irritating, and the heat pumping through the radiators doesn’t help.
●   Acanthosis nigricans  Darkened thick skin on the neck, in the groin, and under the breast, thighs, armpits, or vulva  that look dirty but never come off when you scrub them are signs of  high insulin which is associated with


                                   

●    Headache  :   Hormone changes can trigger headaches in some women.
●    Rare symptoms  :  Insomnia or poor sleep, Mood changes, Hypoglycemia, High blood pressure, 
Hyperkeratosis, Pelvic pain, dry eye, fatty liver, eating disorders, ruptured cyst, Hidradenitis suppurativa. (  is a painful, long-term skin condition that causes abscesses and scarring on the skin. The exact cause of hidradenitis suppurativa is unknown, but it occurs near hair follicles where there are sweat glands, usually around the groin, buttocks, breasts and armpits )

●    Anxiety : 

●    Depression : 

To be diagnosed with PCOS, you must meet at least two of the following three criteria:
- Irregular or absent periods (fewer than eight menstrual cycles per year)
- Blood results or physical signs of hyperandrogenism (high androgen) without another medical cause
- The appearance of small follicles on an ultrasound of the ovaries.

Diagnosis
●   Medical history :  Menstrual periods—how regular they are and the length of time between them This information may help your doctor determine if you are ovulating.
●  Physical examination :  Measure your blood pressure, body mass index (BMI), waist size, hair loss, extra hair on your face , skin discoloration, acne etc.
●  Waist circumference : The risk associated with obesity are independently associated with excess fat. Waist circumference 102cm (40 inches) in males and 88cm (35 inches) in females. Measurement of waist circumference is taken just above the illiac crest.
●  Signs of high Androgen or testosterone :  Abnormal hair growth (specifically on the face, lower abdomen, back, and chest),acne,skin tax,  male pattern baldness (if applicable), and acanthosis nigricans (darkened thick skin on the neck, thighs, armpits, or vulva).
●  Pelvic ultrasound :  Poly-cystic ovaries refer to the presence of 12 or more small follicles in each ovary. The follicles sometimes referred to as cysts, resemble a string of pearls. 
                                                       

                        
●   Lab test :  
●   High Androgen level - Blood tests with high androgen levels (total and free testosterone, DHEA-sulfate) is enough to satisfy the criteria.
 estrogen, and follicle stimulating hormone (FSH),
●   Lipid abnormalities :  High cholesterol to rule out fatty liver.
●  Type 2 Diabetes Glucose tolerance test.
●  Insulin resistance : Insulin  is also a hormone that has been shown to be elevated in women with PCOS. Insulin can contribute to weight gain..  A new hormonal blood test, looking at a woman's AMH  (anti-mullerian hormone) is now being used by some physicians as a diagnostic tool as well
 ● Test your thyroid hormone levels, as thyroid disorders have similar signs and symptoms as PCOS.
●  As PCOS often runs in families, note whether your mother, sisters, or other close relatives have had PCOS or a history of infertility.
●  Endometrial Biopsy :  To determine if your endometrial tissue is in the correct phase or to test for endometrial cancer.The biopsy can be done in your doctor’s office and is relatively painless,  A small amount of tissue is removed from your uterus through a thin catheter placed through the cervix and into the uterus. This tissue is then analyzed in the context of your cycle and examined for cancer cells.
●  Imaging : Trans - vaginal ultrasound to  be performed to rule out PCOS. This test may be familiar to you if you've ever been pregnant. A probe is placed inside the vagina, which allows the physician to examine the reproductive organs, look for abnormalities, and measure the thickness of the endometrium.

Complications

● Infertility  : (Difficulty in getting pregnant)  . An imbalance of sex hormones can stop ovulation by preventing the maturation and/or release of follicles from the ovaries. The follicles are oftentimes mistaken for cysts
● Miscarriage or premature birth 
● Nonalcoholic steatohepatitis — a severe liver inflammation caused by fat accumulation in the liver
● Metabolic syndrome — a cluster of conditions including high blood pressure, high blood sugar, and abnormal cholesterol or triglyceride levels that significantly increase your risk of cardiovascular disease
● Type 2 diabetes or prediabetes
● Obstructive sleep apnea  : Commonly characterized by snoring, is highly prevalent in women with PCOS. Sleep apnea may be caused by increased weight.
● Depression, anxiety and eating disorders
● Abnormal uterine bleeding
● Cancer of the uterine lining (endometrial cancer)

Lifestyle
                   

           
●  Lose weight if you are overweight.

● Staying active by doing some form of physical activity  can improve ovulation and insulin resistance Be like a Grasshopper.
● Brisk walking :  At least half an hour daily.
●  Take adequate quantity of water.

●  Lot of sleep ,
●  Regular bowel movement is also helpful.
●  Regular massage,swimming,dancing
●  Chewing well is important.                         

Exercise

Physical Activity :

Regular physical activity  can help alleviate symptoms of P.C.O.S. Regular exercise and movements throughout the day  helps body to burn sugar and improves sensitivity to insulin.

No matter what your weight, being sedentary and not exercising can raise your risk of metabolic syndrome and Type 2 diabetes. This is where the extra testosterone seen in PCOS can work for you. You will build muscle more easily, so two days of weight training each week will build muscle mass that can help your body use insulin more effectively. Aim to get 30 minutes walk per day of cardiovascular exercise.
Reduce the time you spend sitting. Find ways to break up long times at your desk or watching television or videos in the evening. Add more activity throughout the day. Many fitness trackers now alert you when you have been sitting for an hour without activity.

Yoga

Yoga a form of mind body discipline directed towards  mindful awareness of the self, the breath, and energy., can work wonders. Yoga helps PCOS patients by opening up the pelvic area, releasing stress and promoting relaxation of mind and body. Practicing yoga calms anxiety and reduces the anti Mullerian hormone (AMH),  luteinizing hormone and testosterone in the body. Any women 

 with this syndrome  should do yoga for  about 30 minutes  five days in a week. It would help in reducing testosterone levels to about 30%.

Yoga asanas promotes relaxation and helps in reducing body weight. It relaxes the mind which in turn helps in the regularity of the menstrual cycles.

Surya Namaskar
                                     

Benefit : 

• It helps in improving flexibility, controls blood sugar and aids weight loss.

●   Squat or Garland Pose Malasana (मलासना )

                                      

             

Squatting is one of the most effective ways to tone the entire lower body. As the pelvis descends it encourages the downward flowing energy of Apana Vayu and thus helps in constipation.
To learn to squat or if you are pregnant:Separate your feet about 6 to 8 inches, and place a folded blanket under your heels until you are able to lower your pelvis and maintain balance.

Benefit :

• This asana strengthens abdominal and pelvic muscles, increases blood circulation and aids in digestion.

     ●  Cobra pose  Bhujangasana  (भुजंगासना )

                     

                                                        

Technique :  Lie down on your abdomen by taking legs apart. Keep the palm beside the chest. Breathing in, lift the upper part of your body, up to naval region. Hold it for 10 seconds by feeling the stretch on your abdomen. Repeat this for 3-4 times.

Benefit : 

•        Improves ovarian funtions and helps in relieving deeply stored stress.
•       

Caution: Pregnant women and people with slip disc should avoid this asana.

    ●     Cobblers Pose / Butterfly Pose   Baddha Konasana  :  ( तितली आसन )

Baddha means caught, restrained, Kona means angle.
Technique : Sit in starting position. Bend both the knees and drop the knees on the floor  on both the sides. Hold the toes by interlocking the fingers, move the knees both in upward and down ward direction in normal breathing.

Benefit : 

• This asana opens up the pelvic area, promotes relaxation and relieves period pain.
• The pelvis the abdomen and the back get a plentiful supply of blood and are stimulated.
• It checks irregular menstrual periods and helps the ovaries to function properly.
• Pregnant women who sits in this pose in this pose for a few minutes will have much less pain during delivery and will be free from varicose veins.
• Butterfly pose  is good to keep the lower spine fit. 
• Offer relief from menstrual discomfort and menopause symptoms. 
• Helps in smooth delivery if practiced regularly until late pregnancy.

                                                  

●    The Boat Pose Naukasana (नौकासन )
                                          

                                           
Benefits :

• Apart from helping in weight loss, it improves reproductive health.
• Naukasana strengthens the abdominal muscles.
• It strengthens the muscles of the arms, thighs and shoulders.
• It improves the health of all organs in the abdomen especially the liver, pancreas and kidneys.
• It helps in regulating blood flow at sugar level.

Supta Banda Konasana

Benefits :

• This asana also strengthens the pelvic floor muscles and relaxes the mind and body.

Pranayama          
Fix P.C.O.S  by regular breathing coupled with regulated breath.
Anulom Vilom

Controlled breathing helps in deep relaxation and de-stressing.

Alternate Nose Breathing - Nadi Shodhan  / Anolom Vilom अनुलोम विलोम

                       

Nadi is a Sanskrit word meaning “channel” or “flow” and shodhana means “purification.” Therefore, nadi shodhana is primarily aimed at clearing and purifying the subtle channels of the mind-body organism, while balancing its masculine and feminine aspects. 

The Nadi Shodhan Pranayama calms and centers the mind by bringing into harmony the left and right hemispheres of the brain which correlate to the logical and emotional sides of our personality. The right nostril represents the Ida nadi and is connected with the left brain. The left nostril represents the Pingala nadi and is connected with the right hemisphere of the brain. When we breathe through the alternate nostril in a specific pattern, it brings the balance between both hemispheres of the brain. Nadi shodhan is clearly a yogi's delight for its instant calming effect.

Process :

•  Sit comfortably in an erect position. Keep the head, neck and the spine straight.
•  Rest the left hand on the left knee.
•  Close the right nostril with the tip of right thumb.
• Now breath out slowly through the left nostril.
• Keeping the right nostril closed breathe in slowly and deeply through the left nostril.
• Now close the left nostril with ring finger and little finger of the right hand  and slowly breathe out through the right nostril.
• Now keeping the right nostril still closed, breathe in through the right nostril.
• This completes one entire round of Anuloma -  Viloma.
• Repeat the entire process
• Remember that breathing in and breathing out  should be done very slowly without any noise

Benefits

• Infuses the body with oxygen
• Clears and releases toxins
• Reduces stress and anxiety
• Calms and rejuvenates the nervous system
• Helps to balance hormones
• Supports clear and balanced respiratory channels
• Helps to alleviate respiratory allergies that cause hay fever, sneezing, or wheezing
• Balances solar and lunar, masculine and feminine energies
• Fosters mental clarity and an alert mind
• Enhances the ability to concentrate
• Brings balance to the left and right hemispheres of the brain

                                            

Channels or Nadis

               

                                           

Mudra

Rudra Mudra

Meditation
Stress reduction techniques,which help calm the mind and let you connect with your body these include meditation.
                        

                                      "Nutrition plays an important role in managing PCOS."

Healthy Diet

Have a balanced  carbohydrate diet that is  also  rich in protein and fat  to balance blood sugar levels. Have a balanced carbohydrate diet that is also rich in protein and fat to balance blood sugar levels

Patient who maintain a healthy diet can improve their hormonal function and sustain better health. In P.C.O.S Satvic food plays an important role. fresh home cooked meals, plenty of water and reduced salt intake, three days before the menstrual cycle, will make a difference.

Moderate amounts of fiber, unprocessed low hypoglycemic index grains (oats, quinoa), and foods rich in omega-3 fats such as fish (salmon, tuna, trout),  nuts,seeds, and avocados.

●  Supplements : One can use supplements too in order to beat P.C.O.S. Zinc is an important supplement. It improves energy levels helps with hair loss.. Magnesium improves anxiety  and sleep cycle . Vitamin D boosts bone health and immunity and B 12 helps in  inflammation.

●  Drink more water : Drink 2 liters of water per day flavoring it with fresh citrus, cucumber, mint or berries. Drink moonlight charged water- water kept in  the moonlight overnight-in the morning. Its an Ayurvedic remedy for P.C.O.S.

●  Green leafy vegetables  should be consumed regularly, especially for breakfast and lunch.

●   Keep the amount of carbohydrate foods  per meal moderate and in balance with protein so your blood sugar levels are stabilized.
●  Take fresh food and fresh vegetables (Salads)
●   Supplementing Vitamin D in diet to improve menstrual irregularity and insulin resistance: i.e.Fatty fish, like tuna, mackerel, and salmon
●  Vitamin C rich food : amla,lemon,and habiscus also helps to produce oestrogen
●  Whole cereals: Try to include all cereals in their whole forms because whole grains like whole wheat, parboiled rice,and whole oat provide B - complex vitamins and carbohydrates as a source of energy.

● Balance carbs and proteins : Blend a lean protein source and food rich in complex  carb in your diet. Consume  complex carbohydrates and avoid sugar and refined food.

●   Quality Proteins : Try to add foods in your diet which contains amino acids  essential and non-essential so that your body can use them to produce hormones. For example eggs, non pasteurized dairy,legumes,soaked nut and seeds.

                                                      

●   Good quality fat , Eat healthy fats : Include fats such as desi ghee nuts and seeds in your diet and avoid refined oil completely. Try to consume good quality fats like virgin oils,nuts,seeds,avocados and desi ghee to help your brain  regulate the endocrine functioning in a perfect way.
●  Vitamin & Minerals : Add all the essential vitamins  and minerals like selenium,zinc and chromium to improve your body's insulin sensitivity.
                                                   

●  High fibre & low Fat : Include tomatoes, kale,spinach,almonds and walnuts,olive oil,fruits such as blueberries and strawberries.
                                            

●  Alkaline food : Eat as many vegetables,fruits,dry fruits,sprouts,seeds, and natural foods as you can.

. 

                                                       

Avoid
●  High Glycemic index (GI) Foods : affects your blood sugar level. White sugar - increase in sugar levels. Sweetened juice,canned fruit, Starchy vegetables such as potatoes,corn & peas. Sugary drinks and foods such as soda,juice,cookies and candies.
●  Dairy products :  Allergic reactions ,digestion problems.
●  White flour & white rice : Affects digestive system & supresses immunity system.
●   Gluten grains  : Digestive problems.
●   Red meat  : Affects your hormonal system.
●   Alcohol : Worsens  metabolism of sugar.
●   Hydrogenated oils : Raises bad cholesterol and lowers good cholesterol.
●   Caffeine : Increases estrogen levels and effects fertility.
●   Snacks such as potato chips,Doritos and tortilla chips.

●  Refined grains : Made with white flour (maida) such as white bread,pasta,white rice. Avoiding refined or processed sources of carbohydrates, such as crackers, white bread, white rice, pretzels, and sugary foods like cookies, brownies, and candy is suggested to bring down insulin levels and inflammation. 
●  Avoid junk food and processed food.

                         "Consult a reproductive endocrinologist."

Treatment

 A combination of  naturopathy and yoga allows the restoration of hormonal balance and offer a remedy for anxiety,depression that are common among women with P.C.O.S

●    Acne : Dry skin can exacerbate  or worsen acne. If you notice that you breakout worsen at the winter time, it can become necessary to make changes to your skin care routine. Products containing alcohol should also be avoided because of the drying effect it has on your skin. Try using a moisturizing oil free soap and exfoliant, dead skin can clog pores and cause acne. Aloe vera a good choice. 
                                                

- Or a coconut oil a natural moisturizer.
                                                 

 ●  Obesity :  Obesity due to illness should be treated naturally by changing one's lifestyle.

●     Stress : Since stress worsen PCOS symptoms, it is of utmost importance to relax the mind to keep  the cortisol levels under control. Hence constant relaxation techniques should be incorporated into daily life.

●  Facial hair :  

-  Vaniqa : (eflornithine hydrochloride) is a prescription facial cream that can slow the growth of facial hair in women. It doesn't permanently remove hair, so you need to apply it daily and continue to do so indefinitely. It takes four to eight weeks to become effective. It should not be used while you are pregnant.
  - Waxing and threading can also be done at home or by estheticians. 
-  Laser hair removal  can give you longer-lasting results and you can find these treatments at clinics and spas. These are usually performed by technicians under the supervision of a doctor but without a prescription. Other procedure includes
-  Shaving,chemicals,plucking. 
- Electrolysis : Electrolysis used  to permanently damage individual hair follicles.

● For Dryness : 
-  Watch the Hot Water : When  the outdoor temperature drops, a hot bath or shower may sound inviting, but hot water can strip the skin of its natural oils. Avoid spending a lot of time in hot tubs, saunas or hot baths, and keep showers short and as cool as you can stand the water. Slather on thick cream immediately afterward.

● Regulating a menstrual cycle : Your doctor may feel it necessary to give you a medication called Provera (medroxyprogesterone) which will induce bleeding if you have not had a period in a while. Provera is an oral medication which is taken for five to 10 days and will bring on a period. You may need a blood test prior to beginning this medication to confirm that you are not pregnant. Oral contraceptive pills : Medication such as birth control pills  to regulate the menstrual cycle and reduce androgens. Progestin therapy can also help, plus it may reduce the risk of endometrial cancer. 
● Laproscopic Ovarian Drilling When you have PCOS, your ovaries have a thicker outer layer than normal and make more testosterone. This laparoscopic surgery makes several tiny holes in the outer layer of the ovaries (it is sometimes called "whiffle ball" surgery), which reduces the amount of testosterone made by the ovaries. It has a success rate of about half of women getting pregnant in the first year after surgery. A big advantage is that the procedure is only done once, so it can be less expensive than gonadotropin treatment. Another advantage is that it doesn't increase the risk of multiple pregnancies.

● Assisted Reproductive Technology
-  Intrauterine insemination (IUI) is a fertility procedure timed to coincide with ovulation. Your partner will be asked to produce the semen specimen. The semen is then “washed” or the sperm is separated from other elements of the semen and gathered into a smaller, more concentrated volume. The specimen is placed into a thin, sterilized, soft catheter, and ready for insemination. A speculum, like one used during a gynecological exam, is placed in the vagina and your cervix is gently cleansed. Your doctor will insert the catheter in the vagina and release the sperm into your uterine cavity. Your doctor may allow you to remain lying down for a few minutes after the insemination. Success rates for IUI are approximately 15 percent to 20 percent per cycle and vary based on a number of factors, such as your age, type of ovarian stimulation, motility of sperm, among others
-  When to Seek Help If you have been struggling to get pregnant, you may want to seek the advice of a  reproductive endocrinologist also called “fertility doctors.” These type of doctors specialize in sex hormones and tend to have ultrasound machines in their offices to help determine your cause of infertility and provide the recommended treatment. Coping with infertility is hard on women and couples, especially when it seems that everyone around you is getting pregnant. If you find infertility has taken an emotional toll, consider working with a trained mental health professional or joining an infertility support group in your area. 
-  Androgen Suppressors : Medications which suppress androgen secretion are one option that your doctor may give you. oral contraceptive may help may help, or the doctor may prescribe an antiandrogenic medication, such as xspironolactone (aldactone) Spironolactone inhibits the testosterone secreted by the body, and also competes for hormone receptors in the hair follicles. Receptors are sites on cells which allow hormones or chemical to bind to them, creating a reaction. If another chemical is in the receptor site, androgens cannot bind to them and stimulate the reaction causing hair growth.

● Infertility 

- Ovulation : ● Clomid and Femara It is given to improve ovulation, and it is considered to be the first-line treatment.. Femara (letrozole) may work better than Clomid for women with PCOS. Letrozole doesn’t raise estrogen (like Clomid) but instead makes you produce more FSH. It improves the uterine lining and also seems to result in fewer multiple births. 
- Losing weight can also help accomplish this. In some people, moderate weight loss can help restore ovulation and greatly increase your odds of pregnancy.

If these do not work, the next step will most likely be injectable medications known as gonadotropins. Each month, folicle stimulating hormone (FSH) is secreted by the pituitary which makes an egg follicle grow. Gonadotropins directly increase the amount of FSH circulating in the body, promoting the growth and development of a mature egg. The doctor will most likely monitor your progress through ultrasound and blood tests. Once the doctor feels that you are close to ovulating, she may have you take an injection of human chorionic gonadotropin (HCG) which will trigger your ovulation within 36 hours. This will allow you to more precisely time when to have intercourse or have intrauterine insemination  (IUI). Your doctor will help you identify which choice is better for you.

- In vitro fertilization (IVF) or a (embryo transfer ) 
  Finally a complex process where you will undergo controlled hyperstimulation of your ovaries through injectable medications. This produces many eggs which the doctor will then remove through a surgical procedure. Fertilization takes place outside of the body and in the more controlled environment of the lab. Growing  embroyos are then transferred back into the body, where they will hopefully implant in the uterus and form a viable pregnancy. There are many treatment protocols within the IVF process and your doctor will choose the best one, based on your medical history, age, and diagnosis. If standard IVF does not work for you, it can be used with donor eggs  donor sperm, or with a surrogate as necessary.