Infertility associated with pcos
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INFERTILITY ASSOCIATED WITH PCOS. Dr. Norlia Bahauddin Hospital Kajang. Mdm SH. A 28 year old Malay, nulliparous, married for 2 years. No medical illness. Initially regular menses Past 2 years, menses became oligomenorrhoeic, every 12-20 weeks apart, lasting 2-3 days .

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INFERTILITY ASSOCIATED WITH PCOS

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Infertility associated with pcos

INFERTILITY ASSOCIATED WITH PCOS

Dr. Norlia Bahauddin

Hospital Kajang


Mdm sh

Mdm SH

  • A 28 year old Malay, nulliparous, married for 2 years.

  • No medical illness.

  • Initially regular menses

  • Past 2 years, menses became oligomenorrhoeic, every 12-20 weeks apart, lasting 2-3 days 


Infertility associated with pcos

  • Increase in weight  within 2 years

  • She is a non smoker and non drinker

  • The couple had regular unprotected intercourse

  • Husband healthy, no erectile dysfunction or premature ejaculation


Infertility associated with pcos

  • Obese lady, BMI: 34kg/m². Acne present. No hirsutism seen or signs of insulin resistant such as acanthosisnigrican seen.

  • Ultrasound examination noted polycystic ovaries

  • Investigation result

    • FSH/LH: 5.7/9.1

    • Mid Luteal progesterone: 0.22ng/ml

    • T4/TSH: 2.67/17.2

    • Testosterone: 2.85nmol/L

    • MGTT: Fasting4.6mmol/L / 2H postprandial 8.5mmol/L

    • Pap smear: NILM

    • SFA: normal


Infertility associated with pcos

  • Advised to reduce weight, referred to a dietician.

  • Commenced on ovulation induction.

  • Metformin  given in view of impaired glucose tolerance test.

  • She was started on clomiphene citrate for 3cycles (50mg od x1, 100mg od x2), however failed (no dominant follicle seen during follicular tracking).


Infertility associated with pcos

  • Proceeded for laparoscopic dye test and ovarian drilling. Intraoperatively noted right polyscystic ovary. Both fallopian tubes patent.

  • Given another cycle of clomid 100mg od, which failed .

  • Then given 1 cycle of S/C Puregon(75iu x5/7,150iu x 7/7)

  • Follicular tracking showed a dominant follicle  right ovary (18mm).Triggered with  HCG (IM Pregnyl 10000iu) followed by IUI 36 hours later.


Infertility associated with pcos

  • Unfortunately, subsequent follow up  noted an ectopic pregnancy and a  diagnostic laparoscope showed a left tubal pregnancy and left salphyngectomy was done.


Discussion

DISCUSSION

  • Definition of PCOS, with two out of  three  criteria being diagnostic:

    • polycystic ovaries (12 or more peripheral follicles, 2-9mm ) or increased ovarian volume (greater than 10 cm3)

    • oligo- or anovulation

    • clinical and/or biochemical signs of hyperandrogenism


Infertility associated with pcos

  • PCOS is associated with hyperinsulinemia, obesity, hypertension, dyslipidemia, and an increased prothrombotic state.

  • There is also an increased risk of type 2 diabetes and impaired glucose tolerance, infertility and sleep apnea.


Infertility associated with pcos

  • Anovulation is common among women with PCOS.

  • Hyperandrogenism, in conjuction with hyperinsulinaemia are cardinal features of PCOS .

  • Follicular testosterone level have been shown to be elevated in PCOS.


Infertility associated with pcos

  • High androgen levels may  contribute to  lower fertilization rates.

  • Glycodelin is a secretory protein from the endometrium and is a marker of endometrial receptivity.

  • High androgen levels in PCOS attribute to a reduction in glycodelin and therefore a reduction in endometrial receptivity.


Infertility associated with pcos

  • Management of infertility in PCOS includes lifestyle modification and assisted reproductive technology such as ovulation induction.

  • For overweight women with PCOS who are anovulatory, diet adjustments and weight loss are associated with resumption of spontaneous ovulation in some women


Infertility associated with pcos

  • Central obesity is a major factor influencing outcomes of both treatment of symptoms and infertility in women with PCOS.

  • Obesity is associated with increase in miscarriage, gonadotrophin resistance and reduction in oocyte number.


Infertility associated with pcos

  • Clomiphene citrate is the first-line treatment in  anovulatory patients with PCOS.

  • The cumulative pregnancy rate with clomiphene citrate after 6 months of treatment is between 40% and 50%.

  • Women who remain anovulatory can be stimulated with low dose gonadotropins.


Infertility associated with pcos

  • Patient with PCOS undegoing IVF treatment are at a higher risk to develop OHSS.

  • Higher estradiol concentration and oocyte numbers are found  in those who develop OHSS.


Infertility associated with pcos

  • Metformin as a first line agent in ovulation induction is less effective than clomiphene; lower ovulation and pregnancy rates

  • However, metformin benefits women with clomiphene resistance

  • Non obese PCOS women benefit the most from metformin; improves live birth rate

  • Metformin use is also associated with reduced OHSS


Infertility associated with pcos

  • Metformin reduces serum testosterone and free androgen index, this improves folliculogenesis

  • Serum VEGF and estradiol levels are lower in those on metformin, this helps reduce risk of OHSS


Infertility associated with pcos

  • Surgery can be attempted in cases where ovaries are resistant to stimulation/ovulation induction. 

  • The polycystic ovaries can be treated with a laparoscopic procedure called "ovarian drilling" (A total of 3 to 10 punctures, 7 to 8 mm in depth are made in each ovary depending on its size. Each penetration lasts 4 to 5 seconds).


Infertility associated with pcos

  • This results in resumption of spontaneous ovulations or ovulations after adjuvant treatment with clomiphene or FSH.

  • Unlike ovarian stimulation treatment, drilling is not associated with an increased risk of multiple pregnancy.


Infertility associated with pcos

  • LOD destroys ovarian androgen producing tissue and reduces peripheral conversion of androgens to estrogens.

  • A fall in the serum levels of androgens and LH and an increase in FSH levels occur.

  • This converts an adverse androgen dominant intrafollicular environment to an estrogenic one and restores the hormonal environment.  

  • This can restore ovulatory function


Infertility associated with pcos

  • Anti mullerian hormone (AMH) is a biomarker that has been investigated as a risk factor for OHSS

  • Secreted by granulosa cells in pre-antral and small antral follicles

  • Used to estimate ovarian reserve and predict ovarian response to gonadotrophin stimulation

  • Higher AMH levels is associated with OHSS


Thank you

THANK YOU


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