Infertility in polycystic ovary syndrome: Difference between revisions
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==Management== |
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In accordance with the findings implicating dietary trans fatty acids in the aetiology of ovulatory infertility, by Chavarro JE, Rich-Edwards JW, Rosner BA, Willett WC) in the Am J Clin Nutr. 2007 Jan;85(1):231-7 PMID: 17209201 and in the Obstet Gynecol. 2007 Nov;110(5):1050-8 PMID: 17978119, it is rational to suggest a 100 % trans fat free 'fertility diet' for patients with PCOD who may also desire to become pregnant. A 100% trans fat free diet maybe difficult but worth it in the experience of those who conceived by this method after failure of other methods.[12][13] |
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Regarding diet, intake of [[trans fat]]s seems to particularly increase the risk of infertility in polycystic ovary syndrome, with each 2% increase in the intake of energy from unsaturated trans fats approximately doubling the risk, as compared to intake of equal energy from carbohydrates, n-6 [[polyunsaturated fat]]s or [[monounsaturated fat]]s.<ref>Chavarro JE, Rich-Edwards JW, Rosner BA, Willett WC. ''Dietary fatty acid intakes and the risk of ovulatory infertility.'' Am J Clin Nutr. 2007 Jan;85(1):231-7. [http://www.ncbi.nlm.nih.gov/pubmed/17209201 PMID: 17209201]</ref> |
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12. Chavarro JE, Rich-Edwards JW, Rosner BA, Willett WC. Dietary fatty acid intakes and the risk of ovulatory infertility. |
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Am J Clin Nutr. 2007 Jan;85(1):231-7. PMID: 17209201 |
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13. Chavarro JE, Rich-Edwards JW, Rosner BA, Willett WC. Diet and lifestyle in the prevention of ovulatory disorder infertility. |
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Obstet Gynecol. 2007 Nov;110(5):1050-8. PMID: 17978119 |
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[[Category:Endocrinology]] |
[[Category:Endocrinology]] |
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Revision as of 06:53, 15 July 2011
Polycystic ovary disease (PCOS) is thought to be one of the leading causes of female infertility.[1][2][3][4] Polycystic ovary syndrome is the cause of more than 75% of cases of anovulatory infertility.[5]
Pathophysiology
Not all women with PCOS have difficulty becoming pregnant. For those who do, anovulation is a common cause. The mechanism of this anovulation, is uncertain, but there is evidence of arrested antral follicle development, which, in, turn, may be caused by abnormal interaction of insulin and luteinizing hormone (LH) on granulosa cells.[5]
Endocrine disruption may also directly decrease fertility, such as changed levels of gonadotrophins, hyperandrogenemia and hyperinsulinemia.[6]
Diagnosis
PCOS usually causes infertility associated with anovulation, and therefore, the presence of ovulation indicates absence of infertility, although it does not rule out infertility by other causes.
Ovulation prediction
Ovulation may be predicted by the use of urine tests that detect the preovulatory LH surge, called ovulation predictor kits (OPKs). However, OPKs are not always accurate when testing on women with PCOS.[7] Charting of cervical mucus may also be used to predict ovulation, or certain fertility monitors (those that track urinary hormones or changes in saliva) may be used. Methods that predict ovulation may be used to time intercourse or insemination appropriately.
While not useful for predicting ovulation,[8] basal body temperatures may be used to confirm ovulation. Ovulation may also be confirmed by testing for serum progesterone in mid-luteal phase, approximately seven days after ovulation (if ovulation occurred on the average cycle day of fourteen, seven days later would be cycle day 21). A mid-luteal phase progesterone test may also be used to diagnose luteal phase defect. Methods that confirm ovulation may be used to evaluate the effectiveness of treatments to stimulate ovulation.
Management
Lifestyle modification
For overweight women with PCOS who are anovulatory, diet adjustments and weight loss are associated with resumption of spontaneous ovulation.
Regarding diet, intake of trans fats seems to particularly increase the risk of infertility in polycystic ovary syndrome, with each 2% increase in the intake of energy from unsaturated trans fats approximately doubling the risk, as compared to intake of equal energy from carbohydrates, n-6 polyunsaturated fats or monounsaturated fats.[9]
Medication
For those who after weightloss still are anovulatory or for anovulatory lean women, clomiphene citrate is the principal treatment used to help infertility in PCOS.
Inefficacy of metformin
Previously, metformin was recommended treatment for anovulation. But in the largest trial to date, comparing clomiphene with metformin, clomiphene was more effective than metformin alone.[10] In this trial, 626 women were randomized to three groups: metformin alone, clomiphene alone, or both. The live-birth rates following 6 months of treatment were 7.2% (metformin), 22.5% (clomiphene), and 26.8% (both). The major complication of clomiphene was multiple pregnancy, affecting 0%, 6% and 3.1% of women respectively. The overall success rates for live birth remained disappointing, even in women receiving combined therapy, but it is important to consider that the women in this trial had already been attempting to conceive for an average of 3.5 years, and over half had received previous treatment for infertility. Thus, these were women with significant fertility problems, and the live-birth rates are probably not representative of the typical PCOS woman. Following this study, the ESHRE/ASRM-sponsored Consensus workshop do not recommend metformin for ovulation stimulation.[11] Subsequent randomized studies have confirmed the lack of evidence for adding metformin to clomiphene.[12] It is worth noting that there has been no large scale study of the efficacy of Metformin and / or Clomiphene in patients who are on a trans fat free diet.[13]
Assisted reproductive technology
For patients who do not respond to clomiphene, diet and lifestyle modification, there are options available including assisted reproductive technology procedures such as controlled ovarian hyperstimulation with FSH injections followed by in vitro fertilisation (IVF). Ovarian hyperstimulation with FSH followed by hCG has an associated risk in women with PCOS of ovarian hyperstimulation syndrome — an uncomfortable and potentially dangerous condition with morbidity and rare mortality. Thus recent developments have allowed the oocytes present in the multiple follicles to be extracted in natural, unstimulated cycles and then matured in vitro, prior to IVF. This technique is known as In vitro maturation (IVM).
Surgery
Though surgery is not commonly performed, the polycystic ovaries can be treated with a laparoscopic procedure called "ovarian drilling" (puncture of 4-10 small follicles with electrocautery), which often results in either resumption of spontaneous ovulations or ovulations after adjuvant treatment with clomiphene or FSH.
References
- ^ Goldenberg N, Glueck C (2008). "Medical therapy in women with polycystic ovary syndrome before and during pregnancy and lactation". Minerva Ginecol. 60 (1): 63–75. PMID 18277353.
- ^ Boomsma CM, Fauser BC, Macklon NS (2008). "Pregnancy complications in women with polycystic ovary syndrome". Semin. Reprod. Med. 26 (1): 72–84. doi:10.1055/s-2007-992927. PMID 18181085.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Palacio JR et,al.The presence of antibodies to oxidative modified proteins in serum from polycystic ovary syndrome patients Clin Exp Immunol. 2006 May;144(2):217-22.PMID 16634794
- ^ Azziz R. et.al.The prevalence and features of the polycystic ovary syndrome in an unselected population. J Clin Endocrinol Metab. 2004 Jun;89(6):2745-9. PMID 15181052
- ^ a b Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 17185789, please use {{cite journal}} with
|pmid=17185789instead. - ^ Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1093/humupd/dmq032, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with
|doi=10.1093/humupd/dmq032instead. - ^ "Question about opks with pcos". Retrieved 7 May 2010.
- ^ Guermandi E, Vegetti W, Bianchi MM, Uglietti A, Ragni G, Crosignani P (2001). "Reliability of ovulation tests in infertile women" (– Scholar search). Obstet Gynecol. 97 (1): 92–6. doi:10.1016/S0029-7844(00)01083-8. PMID 11152915.
{{cite journal}}: External link in|format= - ^ Chavarro JE, Rich-Edwards JW, Rosner BA, Willett WC. Dietary fatty acid intakes and the risk of ovulatory infertility. Am J Clin Nutr. 2007 Jan;85(1):231-7. PMID: 17209201
- ^ Legro RS, Barnhart HX, Schlaff WD (2007). "Clomiphene, Metformin, or Both for Infertility in the Polycystic Ovary Syndrome". N Engl J Med. 356 (6): 551–66. doi:10.1056/NEJMoa063971. PMID 17287476.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group (2008). "Consensus on infertility treatment related to polycystic ovary syndrome". Fertil. Steril. 89 (3): 505–22. doi:10.1016/j.fertnstert.2007.09.041. PMID 18243179.
{{cite journal}}: Unknown parameter|month=ignored (help) - ^ Johnson NP, Stewart AW, Falkiner J; et al. (2010). "PCOSMIC: a multi-centre randomized trial in women with PolyCystic Ovary Syndrome evaluating Metformin for Infertility with Clomiphene". Hum Reprod. 25 (7): 1675–83. doi:10.1093/humrep/deq100. PMID 20435692.
{{cite journal}}: Explicit use of et al. in:|author=(help); Unknown parameter|month=ignored (help)CS1 maint: multiple names: authors list (link)