MANAGEMENT OF POLYCYSTIC OVARY SYNDROME IN CASE OF INFERTILITY

INTRODUCTION

POLYCYSTIC OVARY SYNDROME (PCOS) IS THE LEADING CAUSE OF INFERTILITY IN WOMEN. PCOS IS DIAGNOSED IN 75% WOMEN IN INFERTILITY CAUSED BY ANOVULATION. ACCORDING TO AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE (2009), PCOS IS CHARACTERIZED BY CHRONIC OLIGOANOVULATION, HIPERANDROGENISM, AND FOUND POLYCYSTIC MASS BY ULTRASOUND.

INTRODUCTION

THERE ARE VARIES WAYS TO TREAT PCOS : DIET, DRUGS (ALONE OR COMBINATION), AND OPERATIVE. THE STANDARD APPROACH TO INDUCE OVULATION IN PCOS PATIENTS IS WITH CLOMIPHENE CITRATE (OTT ET AL, 2011) WITH THE DEVELOPMENT OF MANAGEMENT IN POLYCYSTIC OVARY SYNDROME CAN INCREASE THE SUCCESS RATE (PREGNANCY RATE = 50% & LIVE BIRTH RATE = 40%) WHETHER IT IS USED ALONE OR IN COMBINATION.

Homburg et al, European Society of Human Reproduction and Embryology

THE STUDY SHOWN THAT REPRODUCTIVE OUTCOME IS SUPERIOR AFTER OVULATION INDUCTION WITH LOW-DOSE FSH WHEN COMPARED WITH CLOMPIHENE CITRATE (CC). CC DOSE OF 50-150 MG/DAY FOR 5 DAYS AT THE 4TH DAY OF MENSTRUATION NOT SHOWN ANY BENEFICIAL EFFECT ON REDUCES THE TIME OF OVULATION.

THE PREGNANCY RATE (PR) IS HIGHER IN LOW-

Morin-Papunen et al, The Endocrine Society (2012)

TREATMENT OF PCOS PATIENTS WITH METFORMIN ALONE OR IN COMBINATION WITH DRUGS INFERTILITY WILL INCREASE PR, BOTH IN OBESE WOMEN (49%) AND NON-OBESE (58.6%). HOWEVER, TO INCREASE LBR (LIVE BIRTH RATE) THE EFFECT OF METFORMIN (NONOBESE = 46.7%; OBESE = 35.7%) WAS NOT SIGNIFICANTLY DIFFERENT FROM THE PLACEBO EFFECT (NON-OBESE = 35.5%; OBESE = 21.9%)

Crosignani et al, Infertility Unit of the First Department Obstetrics and Gynecology, University of Milan, Italy

DEMONSTRATED THAT THE NEGATIVE EFFECTS OF OBESITY ON FERTILITY ASSOCIATED WITH THE IRREGULAR MENSTRUATION, CHRONIC ANOVULATION, AND INFERTILITY. THE DIET TO LOSE WEIGHT INCREASE MENSTRUAL CYCLE, OVULATION AND FERTILITY. FROM 33 PATIENTS WITH OVERWEIGHT AND CHRONIC ANOVULATION, WITH 5-10% WEIGHT LOSS, 18 OF THESE PATIENTS HAD A REGULAR MENSTRUAL CYCLE IMPROVEMENT AND 15 EXPERIENCED SPONTANEOUS OVULATION, AND 10 OTHERS WERE

Amer, sa. European Society of Human Reproduction and Embryology, 2008

LOD WHEN COMPARED WITH CLOMIPHENE CITRATE AS A FIRST-LINE TREATMENT OF PCOS, PR AND LBR REMAINED HIGHER WITH CLOMIPHENE CITRATE (PR = 44%) AS THE FIRST CHOICE OF PCOS THAN LOD (PR = 27%). HOWEVER, IN PATIENTS WHO ARE RESISTANT TO CLOMIPHENE CITRATE OR FAILS, LOD IS THE BEST CHOICE AS A FIRST-LINE TREATMENT (PR = 55%). THE RESULTS SHOWED DOUBLED PR IN LOD WHEN COMPARED WITH CLOMIPHENE CITRATE IN

DISCUSSION

OTHER OPINION FROM AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE (2009) AGREED WITH THE MANAGEMENT OF WEIGHT LOSS DIETS COMBINED WITH MEDICAL THERAPY IN PATIENTS WITH PCOS IN ORDER TO RAISE THE PR. THIS STUDY DEMONSTRATES A SIGNIFICANT DIFFERENCE IN PATIENTS WITH A HIGH BMI (BMI RANGE OF 28.2 TO 34.1; PR = 37%) WITH A LOW (BMI RANGE OF 15.8 TO 28.0; PR = 62%)

DISCUSSION

THE NEW ENGLAND JOURNAL OF MEDICINE (2010) STATED THAT THERE IS NO SIGNIFICANT ADVANTAGE ON COMBINATION THERAPY WITH METFORMIN-CLOMIPHENE CITRATE COMPARED WITH CLOMIPHENE CITRATE THERAPY ALONE IN IMPROVING THE LBR. A COMBINATION OF AN INCREASE IN PR HAVE BETTER RESULTS. THE USE OF CLOMIPHENE CITRATE AS A FIRST-LINE TREATMENT INDIVIDUALLY

DISCUSSION

BASED ON THE TEXTBOOK THE POLYCYSTIC OVARY SYNDROME : CURRENT CONCEPTS ON PATHOGENESIS AND CLINICAL CARE, IT SAYS THAT TREATMENT WITH CLOMIPHENE CITRATE WAS GIVEN A STARTING DOSE OF 50 MG / DAY (1 TABLET) FOR 5 DAYS STARTING ON DAY 3-5 IN THE MENSTRUAL CYCLE (THE FIRST DAY OF MENSTRUATION IS CONSIDERED AS THE FIRST DAY OF THE CYCLE). IT CAN INCREASE THE PR UP TO 40-50%.

DISCUSSION

AMERICAN JOURNAL OF OBSTETRIC AND GYNECOLOGY (2009) STATED THAT THE MOST IMPORTANT THING TO DO WITH CCRESISTANCE PATIENTS IS TO IMPOSE A STAIR-STEP PROTOCOL AT DOSES GIVEN CLOMIPHENE CITRATE STARTING FROM 50 MG / DAY TO A MAXIMUM DOSE OF 150 MG / DAY.

DISCUSSION

DEPARTMENT GYNECOLOGY ENDOCRINOLOGY AND REPRODUCTIVE AUSTRIA (2010) HAS THE SAME OPINION THAT LOD CAN NOT BE RECOMMENDED AS FIRST-LINE THERAPY FOR ANOVULATORY WOMEN. SHOULD CONSIDER THAT LOD MAY CAUSE A DECREASE IN OVARIAN RESERVE DUE TO SURGICAL DESTRUCTION OF THE OVARIAN CAPSULE AND/ THE FORMATION OF ADHESIONS, DAMAGE TO THE OVARIES,

DISCUSSION

EUROPEAN SOCIETY OF HUMAN REPRODUCTION AND EMBRYOLOGY (2011) STATED THAT IN PCOS PATIENTS WITH CLOMIPHENE CITRATE RESISTANCE CAN ALSO BE TREATED LAPAROSCOPICALLY ELEKTROCAUTER, WHICH HAS A HIGHER LBR (33%) COMPARED TO ADMINISTRATION OF RECOMBINANT FSH (5%). RADICAL OPERATIVE TREATMENT IN CASES OF PCOS HAVE MANY LEFT BECAUSE THEY RISK CONSIDERABLE DAMAGE TO THE ORGAN.

CONCLUSION

CONSERVATIVE THERAPY THROUGH DIET IS TO EXPECT A DECLINE OF BMI <28 COMBINED WITH MEDICAL THERAPY WITH CLOMIPHENE CITRATE WITH A STARTING DOSE OF 50 MG / DAY (1 TABLET) FOR 5 DAYS STARTING ON DAY 3-5 IN THE MENSTRUAL CYCLE. IN THE CASE OF RESISTANCE TO CLOMIPHENE CITRATE, THE BEST THERAPY IS TO INCREASE THE DOSE OF CLOMIPHENE CITRATE IN ACCORDANCE WITH THE STAIRSTEP PROTOCOL AND LAPAROSCOPY

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