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The condition, polycystic ovarian syndrome, known as PCOS, is the commonest
cause of ovulation disorders (90%) in women in the reproductive
age. Generally the treatment of infertility associated with
PCOS patients is very successful. It is a familial condition and the
cause is not yet fully understood.
Polycystic ovarian syndrome is frequently associated with weight gain,
excessive hair growth in the face and body, irregular, infrequent or absent
periods, infrequent or absent ovulation, miscarriage and infertility. It can be
found in apparently normal women, too. There are long-term risks of developing
diabetes, cardiovascular disease and cancer of the womb.
It is typically diagnosed on
transvaginal ultrasound , which may show the typical ‘String of Pearls’
appearance. On laparoscopy
( which allows direct inspection of the ovaries), the ovaries will appear
enlarged and polycystic. FSH levels are low or normal, LH levels are often
raised. The levels of androgens and testosterone may be raised.
A battery of tests are ordered to determine if the responsibility for the
ovulatory disturbance lies with any another condition such as thyroid or
pituitary disorders, age related ovarian failure, stress, ovarian cysts/tumors,
etc.
Weight loss in those who are over weight, is a simple measure which may restore
menstruation and ovulation in patients with polycystic ovarian syndrome.
Induction of ovulation
with letrozole or clomiphene tablets is the first choice and is an effective treatment for
polycystic ovarian syndrome (PCOS). It results in restoring menstruation and
ovulation in about 70% of women and 30% will conceive within three months of
treatment.
When there is failure to respond , metformin, greatly enhances the effectiveness
of oral clomiphene therapy. Many women with PCOS have decreased sensitivity to
insulin, and their bodies overcompensate by over-producing insulin. Elevated
levels of insulin are common in women with PCOS, whether they are obese or
thin. Some experts believe that this excess insulin is the underlying cause of
PCOS because insulin stimulates androgen production and effects follicular
development. Metformin (oral anti-diabetic drug) reduces the serum insulin
levels in the blood consequently successfully restores regular menstrual cycles
and fertility. In women with PCOS, miscarriage rates after conception are
higher than normal. Metformin is also known to reduce abortion rates in PCOS
patients and is often continued till the third month of pregnancy.
Treatment of anovulation when combined with metformin , a
low glycaemic index diet and a moderate exercise program provides much
better results while providing significant health benefits.
The metformin medication is started gradually. During the first 3-4 days a
single tablet of the Metformin is taken. Every 3-4 days an additional tablet is
added until three tables daily (daily dose1500-1800 mg) are tolerated with
minimal stomach upset or diarrhoea (the usual transient side effects when
starting this medication).
Ultrasound monitoring is very important from the start of each ovarian
stimulation cycle.
If the patient does not conceive after three to four months of a particular
therapy, the case is reviewed to determine whether other therapies may be more
appropriate.
Surgery ie ovarian drilling
(LEOS) is recommended should the medical treatment fail. Many women who
failed to ovulate with clomiphene or Metformin therapy will respond when these
medications are reintroduced to the system after ovarian drilling .After
surgery, ovulation occurs spontaneously, too, in a large number of women.
If this fails after a three to four month trial, controlled ovarian stimulation
with FSH or HMG combined with HCG is used. Polycystic ovaries are sensitive to
stimulation by hormones . The dose has to be adjusted according to the
individual patient’s response and close monitoring of follicular growth
/treatment is essential. Monitoring techniques (such as ultrasound scan and
blood tests) are used to strike a balance between getting adequate number of
eggs ( follicles) while minimizing the risk of multiple pregnancy and avoiding
ovarian hyperstimulation syndrome (OHSS).
Ovarian Hyperstimulation Syndrome (OHSS) is a side-effect that can occur during
infertility treatment with ovulation inducing drugs. Symptoms of this syndrome
may include ovarian enlargement, accumulation of fluid in the abdomen , pain in
the abdomen and gastrointestinal disorders (nausea, vomiting, diarrhoea).
Severe cases of OHSS are however very rare (1-2% of cases).
Ovarian cysts filled with fluid are relatively common especially when the
ovaries are being stimulated with drugs to aid conception and usually disappear
without treatment.
Weight control/loss plays a crucial role in the control of the symptoms of
PCOS. Low-dose contraceptive pills are recommended to restore menstrual
regularity in PCOS women who do not wish to conceive. Other hormone treatments
such as progesterone tablets may also be recommended to protect against cancer
of the uterus. In women with excessive hair growth or severe acne, treatment
with anti-androgens may be used.
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