Munro, M. G., Balen, A. H., Cho, S., Critchley, H. O. D., Díaz, I., Ferriani, R., Henry, L., Mocanu, E., & van der Spuy, Z. M. (2022). The FIGO Ovulatory Disorders Classification System. Human Reproduction. https://doi.org/10.1093/humrep/deac180
Munro MG, Balen AH, Cho S, Critchley HOD, Díaz I, Ferriani R, Henry L, Mocanu E, van der Spuy ZM. The FIGO Ovulatory Disorders Classification System. Human Reproduction. 2022. doi:10.1093/humrep/deac180
Munro, Malcolm G., et al. "The FIGO Ovulatory Disorders Classification System." Human Reproduction, 2022.
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FIGO Proposes an Ovulatory Disorders Classification of Four Types
FIGO proposed a system that sorts ovulatory disorders into four types: hypothalamic, pituitary, ovarian and PCOS (now also called PMOS). Experts, societies, journals and lay groups took part in the Delphi surveys. In round four, 95% of 39 respondents supported the draft system. Ten lay respondents gave mixed support.
Key Findings
Of 88 invitations to societies, journals and experts, 46 people from all six continents joined round 1.
In round 2, an anatomic system with a separate PCOS category drew general support (mean score 7.1). Using the Rotterdam Criteria to define PCOS did not reach consensus, with 22.0% disagreeing.
In round 4, 95% of 39 respondents supported the draft system (mean score 8.0), and 2.6% disagreed.
In the lay round, all 10 respondents were women. The draft's mean score was 4.9, and 33% agreed it was understandable.
The proposed system has three levels: four types, a second layer using the GAIN-FIT-PIE mnemonic, and a third level naming specific entities.
Interpretation
This study used a Delphi process. Experts, societies, journals and lay people answered surveys over four rounds to build the system. Most expert and institutional respondents backed the final draft. Lay respondents gave more mixed feedback. The authors say that pinpointing the exact site and cause is still "somewhat aspirational." They also say the system only applies once doctors have already found an ovulatory disorder. The findings support more study of how this system works in real clinics.
RRM Context
Restorative reproductive medicine looks for the cause of a problem before treating it. The system fits that idea. The system sorts ovulatory disorders by whether the fault sits in the hypothalamus, pituitary or ovary. The paper puts single cycles without ovulation in the range of 3.7–26.7% among women with normal regular cycles. The paper gives PCOS its own category.
Our editorial summary of this paper, not the article's abstract.
Abstract
Ovulatory disorders are common causes of amenorrhea, abnormal uterine bleeding and infertility and are frequent manifestations of polycystic ovary syndrome (PCOS). There are many potential causes and contributors to ovulatory dysfunction that challenge clinicians, trainees, educators, and those who perform basic, translational, clinical and epidemiological research. Similarly, therapeutic approaches to ovulatory dysfunction potentially involve a spectrum of lifestyle, psychological, medical and procedural interventions. Collaborative research, effective education and consistent clinical care remain challenged by the absence of a consensus comprehensive system for classification of these disorders. The existing and complex system, attributed to the World Health Organization (WHO), was developed more than three decades ago and did not consider more than 30 years of research into these disorders in addition to technical advances in imaging and endocrinology. This article describes the development of a new classification of ovulatory disorders performed under the aegis of the International Federation of Gynecology and Obstetrics (FIGO) and conducted using a rigorously applied Delphi process. The stakeholder organizations and individuals who participated in this process comprised specialty journals, experts at large, national, specialty obstetrical and gynecological societies, and informed lay representatives. After two face-to-face meetings and five Delphi rounds, the result is a three-level multi-tiered system. The system is applied after a preliminary assessment identifies the presence of an ovulatory disorder. The primary level of the system is based on an anatomic model (Hypothalamus, Pituitary, Ovary) that is completed with a separate category for PCOS. This core component of the system is easily remembered using the acronym HyPO-P. Each anatomic category is stratified in the second layer of the system to provide granularity for investigators, clinicians and trainees using the GAIN-FIT-PIE mnemonic (Genetic, Autoimmune, Iatrogenic, Neoplasm; Functional, Infectious and Inflammatory, Trauma and Vascular; Physiological, Idiopathic, Endocrine). The tertiary level allows for specific diagnostic entities. It is anticipated that, if widely adopted, this system will facilitate education, clinical care and the design and interpretation of research in a fashion that better informs progress in this field. Integral to the deployment of this system is a periodic process of reevaluation and appropriate revision, reflecting an improved understanding of this collection of disorders.
Clinical Guidelines and Standards › Diagnostic Criteria and Classification › Staging and Classification Systems · Menstrual Cycle › Cycle Disorders › Ovulatory Disturbances
Malcolm G Munro, Adam H Balen, SiHyun Cho, Hilary O D Critchley, Ivonne Díaz, Rui Ferriani, Laurie Henry, Edgar Mocanu, Zephne M van der Spuy
Ganesh Acharya, Georgios Adonakis, Sadiah Ahsan, Taghreed AIhaidari, Tengiz Asatiani, Ricardo Azziz, Adam Balen, Michela Bedard, Jennifer Blake, Veronica Chamy, Ying Cheong, Vincent Y T Cheung, Si Hyun Cho, Hilary Critchley, Jose Teixeira da Silva, Ivonne Diaz, Colin Duncan, Amelie Ekersley, Roberto Epifanio-Malpassii, Abimbola Famuyide, Linda Giudice, Maargarita Gurevich, Sioban Harlow, Roger Hart, Oskari Heikinheimo, Sulaiman Heylen, Richard Kennedy, Anna Klepchuckova, Petr Krepelka, Paul le Roux, Kateryna Levchenko, Dimitrios Loutradis, Erica Marsh, Noni Martins, Raj Mathur, Thabo Matsaseng, Rui Miguelote, Malcolm Munro, Eugene Ngoga, Michelle Nisolle, Robert Norman, Masanori Ono, Axelle Pintiaux, Gunda Pristauz-Telsnigg, Diana Ramasauskaite, Pernille Ravn, Jose Reis, Peter Roos, Irena Rozic, Anibal Scarella, Katsiaryna Sharai, Alena Shibut, Sony Sierra, Anne Steiner, Dominic Stoop, Bettina Toth, Zephne Van Der Spuy, Saskia Williams, Lauren Wise, Anusch Yazdani, Liudmila Zhaunova, Meggan Zunckel, Karabo Zwane, 0000-0002-1677-0822, 0000-0003-2138-3752
M Munro, A Balen, S Cho, H Critchley, I Díaz, R Ferriani, L Henry, E Mocanu, Z Spuy, G Acharya, G Adonakis, S Ahsan, T AIhaidari, T Asatiani, R Azziz, M Bedard, Jen Blake, Jenny Blake, J Blake, V Chamy, Y Cheong, V Cheung, J Silva, I Diaz, C Duncan, A Ekersley, R Epifanio-Malpassii, A Famuyide, L Giudice, M Gurevich, S Harlow, R Hart, O Heikinheimo, S Heylen, Rick Kennedy, Dick Kennedy, Rich Kennedy, R Kennedy, A Klepchuckova, P Krepelka, P Roux, K Levchenko, D Loutradis, E Marsh, N Martins, R Mathur, T Matsaseng, R Miguelote, E Ngoga, M Nisolle, Bob Norman, Rob Norman, Bobby Norman, R Norman, M Ono, A Pintiaux, G Pristauz-Telsnigg, D Ramasauskaite, P Ravn, J Reis, Pete Roos, P Roos, I Rozic, A Scarella, K Sharai, A Shibut, S Sierra, A Steiner, D Stoop, B Toth, S Williams, L Wise, A Yazdani, L Zhaunova, M Zunckel, K Zwane
PMID 35984284 35984284 DOI 10.1093/humrep/deac180 10.1093/humrep/deac180 Munro et al. 2022, Munro 2022
