Only 14 pages are availabe for public view
Polycystic ovary syndrome (PCOS) is one of the most
common endocrinopathies, affecting 5–10% of women of
The evaluation of women with presumed PCOS desiring
pregnancy should exclude any other health issues in the
woman or infertility problems in the couple. Before any
intervention is initiated, preconceptional counselling should
be provided emphasizing the importance of life style,
especially weight reduction and exercise in overweight
Treatment of adverse lifestyles, including obesity and
physical inactivity, should precede ovulation induction.
Weight loss prior to infertility treatment improves
ovulation rates in women with PCOS, but there are limited
data that it improves fecundity or lowers pregnancy
The ideal amount of weight loss is unknown, but a 5%
decrease of body weight might be clinically meaningful.
Anovulatory infertility is associated with polycystic ovary
syndrome (PCOS) in the majority of cases and it appears to
be difficult to manage safely and successfully with OI drug
therapy in this population. The reviewed evidence was
obtained from randomized controlled studies of small to
moderate sample size, short duration, and limited
methodology. The investigators used different approaches,
treatment protocols, study population, definitions of
outcome measures and types of outcomes. The question on
which is the safest and the most effective OI drug therapy
in these women does not have a clear answer yet.
According to the available evidence:
Clomiphen citrate (C.C) therapy remains the first choice of
OI drug therapy because of its relative safety, effectiveness
in achieving ovulation, simple mode of administration and
relatively low cost. However, success in achieving
ovulation equates with success in achieving pregnancy in
only half of cases. The increased risk of multiple
pregnancies associated with the use of CC should also be
Aromatase inhibitors have been suggested as an alternative
treatment to clomiphene as the discrepancy between
ovulation and pregnancy rates with clomiphene citrate has
been attributed to its anti-estrogenic action and estrogen
receptor depletion. Letrozole, the most prevalently used
antiaromatase for this indication, has been shown to be
effective, in early trials, in inducing ovulation and
pregnancy in women with anovulatory PCOS and
inadequate clomiphene response.
Metformin as a pre-treatment and co-treatment with CC
seems successful in increasing chances of achieving
pregnancy in selected cases and has been proposed as a
sequential treatment before the use of gonadotrophins.
However, data regarding its use alone or as an adjunct to
CC remain to be confirmed before recommending it as a
In women who do not ovulate or do not conceive in
response to CC therapy, gonadotrophin therapy is the next
medication of choice. It is still not certain whether any
type of gonadotrophin preparations currently available is
superior in terms of improving pregnancy rates and
reducing complication rates. Low-dose gonadotrophin
regimens (regardless of preparations used) may be
considered in order to reduce the incidence of multiple
follicle developments and the associated complications.
Oyulation induction (OI) drug therapy using
gonadotrophins should be restricted to centers with the
expertise and the equipment necessary to make appropriate
clinical decision relating to the treatment and management
of the associated complications.
Women with PCOS considering OI drug therapy to manage
their anovulatory infertility should be aware that:
Regardless of the approach used, there appear to be at
increased risk for multifollicular development and
spontaneous abortion; the risk of developing serious
complications such as multiple pregnancies and ovarian
hyperstimulation syndrome appears to be higher when
gonadotrophin therapy is used.
Surgical approaches to ovulation induction have developed
from the traditional wedge resection to modern day
minimal access techniques, usually employing laparoscopic
ovarian diathermy or laser
Laparoscopic ovarian surgery (LOS) can achieve
unifollicular ovulation with no risk of OHSS or high-order
multiples. LOS is an alternative to gonadotrophin therapy
for CC-resistant anovulatory PCOS. The risks of surgery
are minimal and include the risk of laparoscopy, adhesion
formation and destruction of normal ovarian tissue.
Minimal damage should be caused to the ovaries. Irrigation
with an adhesion barrier may be useful, but there is no
evidence of efficacy from prospective studies. Surgery
should be performed by appropriately trained personnel
Recommended third-line treatment is in vitro fertilization
(IVF), in women with PCOS who do have associated
pathologies, IVF is indicated, such as in case of tubal
damage, severe endometriosis, preimplantation genetic
diagnosis and male factor infertility.
IVF is a reasonable option, because the number of multiple
pregnancies can be kept to a minimum by transferring
small numbers of embryos.
The increase in the cycle cancellation rate in women with
PCOS appears to be due to absent or limited ovarian
response or due to increased OHSS.but this can be
overcome by close ultrasonic folliculometry.