Endocrine Abstracts (2009) 20 S1.4

Treatment of infertility in women with PCOS

Kursad Unluhizarci

Department of Endocrinology, Erciyes University Medical School, Kayseri, Turkey.

Polycystic ovary syndrome (PCOS) is one of the most common endocrinopathies, affecting 5–10% of premenopausal women. Anovulatory infertility is an important feature of PCOS and the optimal treatment for infertile women with PCOS has not yet been defined. Weight loss is recommended as the first-line therapy in obese women with PCOS desiring pregnancy. It is clear that regular physical activity is an important component of weight loss programs since it is associated with better long-term weight loss maintenance. Many studies have shown that weight loss is associated with improved spontaneous ovulation rates in women with PCOS. Among the pharmacologic agents, clomiphene citrate (CC) remains the treatment of first choice for induction of ovulation in anovulatory women with PCOS. There are relatively few adverse effects and requires little ovarian response monitoring. There are no specific exclusion criteria for women with anovulatory PCOS who have normal baseline FSH and estradiole levels. However, older patients may show less response. Treatment generally should be limited to six ovulatory cycles and the starting dose is generally 50 mg/day, for 5 days. Common side effects are hot flushes, headaches and visual complaints. Although there are very limited experience, tamoxifen can be considered in women who are intolerable to hot flushes. There is considerable interest for insulin sensitizers (metformin, rosiglitazone and pioglitazone) in the treatment of women with PCOS. Metformin should be the choice if an insulin sensitizer is considered in the treatment of PCOS women. Although oligomenorrhea improves in some women with PCOS, the degree of improvement in ovulation frequency is similar to that obtained with weight reduction. Insulin sensitizers should not be used indiscriminately and should be restricted to those patients with glucose intolerance and/or metabolic syndrome. Another approach for the treatment of anovulatory infertility in women with PCOS is gonadotropin treatment. The use of exogeneous gonadotropins is associated with increased chances for multiple pregnancy and therefore, intense monitoring of ovarian response is required. Adherence to the chronic low-dose-regimen of FSH (37.5–50 IU/day) administration should markedly reduce the likelihood of excessive ovarian stimulation, namely ovarian hyperstimulation syndrome (OHSS). This issue should be discussed with the patient before ovulation induction. The duration of gonadotropin therapy generally should not exceed six ovulatory cycles. Laparoscopic ovarian surgery (LOS) may be used in CC resistant women with anovulatory PCOS. Mostly employed methods for LOS include diathermy and laser, known as ‘ovarian drilling’. Between 4 and 10 punctures have been performed, and premature ovarian failure is a concern particularly in women who had a large number of punctures. Finally, after failure of weight reduction, anti-estrogen therapy or LOS and in women who have associated pathologies such as tubal damage, male factor infertility, in vitro fertilization is indicated.

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