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Chronic anovulation is probably the major cause of human infertility and is essentially associated with four distinct endocrine conditions; hyperprolactinemic anovulation, hypogonadotrophic anovulation, normo-gonadotrophic anovulation and hypergonadotrophic anovulation. Hyperprolactinaemia and microprolactinoma are frequent findings in young women and excessive prolactin secretion impairs ovarian function causing anovulatory subfertility. Dopaminergic treatment restores ovarian function and shrinks prolacinoma. In these patients restoration of fertility with prolactin lowering drugs does not increase the incidence of multiple pregnancies or early pregnancy loss. In the vast majority of hyperprolactinemic women pregnancy is safe and could be beneficial. Cabergoline is the most effective and tolerated of the antiprolactinemic drugs. Hypogonadotrophic anovulation is frequently associated with acute or chronic emotional stress and in this case the patient should be counselled. Explanation and reassurance are the first important management steps. The use of pulsatile gonadotrophin-releasing hormone is the best strategy to induce fertility. Patients with normogonadotrophic anovulation are likely to have polycystic ovary. The most cost effective profertility treatment is the administration of an anti-oestrogen such as clomiphene or tamoxifen. The second choice therapy for patients with normogonadotrophic anovulation is ovarian stimulation with human gonadotrophin preparations. Low dose modifications give pregnancy rates lower than that with the traditional high-dose step-up protocol and intensive monitoring is required, but multiple pregnancies are less frequent. No treatment is available to enable women with hypergonadotrophic anovulation to conceive. Fertility in these patients can be promoted only by an egg donation programme.

Despite sporadic ovarian follicle development, hormonal contraception consistently and uniformly prevents steroidogenesis and ovulation. For their suppressive activity on ovarian androgen production, oral contraceptives remain the treatment of choice for acne and hirsutism in most hyperandrogenic women. Inhibition of the synthesis of endometrial estrogen receptors explains the effectiveness of hormonal contraception in the therapy of dysfunctional uterine bleeding and in the treatment of pain associated with pelvic endometriosis. Through the inhibition of ovarian cyclicity, the contraceptive pill lowers the incidence of functional ovarian cysts, benign breast disease, dysmenorrhea and premenstrual syndrome and shows a consistent and long-lasting protection against ovarian and endometrial cancer.

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