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Polycystic Ovarian Syndrome (PCOS)
affects 1 in 10 women of childbearing age and have important metabolic and
reproductive repercussion.[1]
The treatment approach varies per the age of the patient, desire for pregnancy
and the presenting symptoms.
Approximately
80% of women who suffer from anovulatory infertility have PCOS. The treatment
approaches towards ovulation induction varies per efficacy, patient BMI and
other associated metabolic abnormalities.
A recent
paper published in the December issue of Human Reproduction Update summarizes
the evidence based recommendations for the management of anovulatoryinfertility in PCOS patients.[2]
The evidence will form the basis for WHO
to develop global guidelines. Management includes lifestyle changes,
pharmacotherapy, bariatric surgery and laparoscopic surgery.
Lifestyle
management, weight loss and exercise is recommended as the first line of treatment
to improve general health and decrease insulin resistance. Morbidly obsess women
should seek expert advice. At present, there is no evidence supporting the role
of bariatric surgery in PCOS associated infertility. [3]
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Clomiphene
citrate is recommended as primary agent to bring about ovulation. It is simple,
inexpensive and induces ovulation in 75% of the patients.[4]
Letrozole, an aromatase inhibitor is fast catching on clomiphene citrate as
first place option.[5]
Metformin
alone is not very effective in improving the live birth rates. It is added to
clomiphene citrate regimen in older women with visceral obesity.
Gonadotrophins
and laparoscopic ovarian drilling are reserved as second line of treatment in
patients who do not respond to lifestyle modification and oral therapies. Gonadotropin
releasing hormone (GnRH) antagonist protocol is safe and combined with IVF.
When GnRH agonist is the choice for treatment, metformin should be used as an adjunct
to reduce the risk of ovarian hyperstimulation syndrome(OHSS).
Laparoscopic
ovarian drilling is specifically used when there are other indications for laparoscopic
surgery. It should not be used as first line of treatment. Concerns about long
term effect of drilling on ovarian functions are still unanswered. [6]
IVF can be
of use in those patients who do not respond to lifestyle modifications and oral
ovulation induction drugs. It is specifically useful in those patients who also
have additional causes for infertility.
No evidence supported
the use of acupuncture or herbal remedies in ovulation induction.
[1] https://www.womenshealth.gov/publications/our-publications/fact-sheet/polycystic-ovary-syndrome.html
[2] https://humupd.oxfordjournals.org/content/22/6/687.abstract
[3] https://www.ncbi.nlm.nih.gov/pubmed/27965894
[4] https://www.ncbi.nlm.nih.gov/pubmed/27151490
[5] https://www.ncbi.nlm.nih.gov/pubmed/27866938
[6] https://www.ncbi.nlm.nih.gov/pubmed/22696324
