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Polycystic Ovarian Syndrome
The condition, polycystic ovarian syndrome, known as PCOS, is the commonest cause of ovulation disorders (90%) in women in the reproductive age. Generally the treatment of infertility associated with PCOS patients is very successful. It is a familial condition and the cause is not yet fully understood.
Polycystic ovarian syndrome is frequently associated with weight gain, excessive hair growth in the face and body, irregular, infrequent or absent periods, infrequent or absent ovulation, miscarriage and infertility. It can be found in apparently normal women, too. There are long-term risks of developing diabetes, cardiovascular disease and cancer of the womb.

It is typically diagnosed on transvaginal ultrasound , which may show the typical ‘String of Pearls’ appearance. On laparoscopy ( which allows direct inspection of the ovaries), the ovaries will appear enlarged and polycystic. FSH levels are low or normal, LH levels are often raised. The levels of androgens and testosterone may be raised.

A battery of tests are ordered to determine if the responsibility for the ovulatory disturbance lies with any another condition such as thyroid or pituitary disorders, age related ovarian failure, stress, ovarian cysts/tumors, etc.

Weight loss in those who are over weight, is a simple measure which may restore menstruation and ovulation in patients with polycystic ovarian syndrome.

Induction of ovulation with clomiphene tablets is the first choice and is an effective treatment for polycystic ovarian syndrome (PCOS). It results in restoring menstruation and ovulation in about 70% of women and 30% will conceive within three months of treatment. 

When there is failure to respond , metformin, greatly enhances the effectiveness of oral clomiphene therapy. Many women with PCOS have decreased sensitivity to insulin, and their bodies overcompensate by over-producing insulin. Elevated levels of insulin are common in women with PCOS, whether they are obese or thin. Some experts believe that this excess insulin is the underlying cause of PCOS because insulin stimulates androgen production and effects follicular development. Metformin (oral anti-diabetic drug) reduces the serum insulin levels in the blood consequently successfully restores regular menstrual cycles and fertility. In women with PCOS, miscarriage rates after conception are higher than normal. Metformin is also known to reduce abortion rates in PCOS patients and is often continued till the third month of pregnancy.

Treatment of anovulation when combined with metformin , a low glycaemic index diet and a moderate exercise program provides much better results while providing significant health benefits.

The metformin medication is started gradually. During the first 3-4 days a single tablet of the Metformin is taken. Every 3-4 days an additional tablet is added until three tables daily (daily dose1500-1800 mg) are tolerated with minimal stomach upset or diarrhoea (the usual transient side effects when starting this medication).

Ultrasound monitoring is very important from the start of each ovarian stimulation cycle.

If the patient does not conceive after three to four months of a particular therapy, the case is reviewed to determine whether other therapies may be more appropriate.

Surgery ie ovarian drilling (LEOS) is recommended should the medical treatment fail. Many women who failed to ovulate with clomiphene or Metformin therapy will respond when these medications are reintroduced to the system after ovarian drilling .After surgery, ovulation occurs spontaneously, too, in a large number of women.

If this fails after a three to four month trial, controlled ovarian stimulation with FSH or HMG combined with HCG is used. Polycystic ovaries are sensitive to stimulation by hormones . The dose has to be adjusted according to the individual patient’s response and close monitoring of follicular growth /treatment is essential. Monitoring techniques (such as ultrasound scan and blood tests) are used to strike a balance between getting adequate number of eggs ( follicles) while minimizing the risk of multiple pregnancy and avoiding ovarian hyperstimulation syndrome (OHSS).

Ovarian Hyperstimulation Syndrome (OHSS) is a side-effect that can occur during infertility treatment with ovulation inducing drugs. Symptoms of this syndrome may include ovarian enlargement, accumulation of fluid in the abdomen , pain in the abdomen and gastrointestinal disorders (nausea, vomiting, diarrhoea). Severe cases of OHSS are however very rare (1-2% of cases).

Ovarian cysts filled with fluid are relatively common especially when the ovaries are being stimulated with drugs to aid conception and usually disappear without treatment.

Weight control/loss plays a crucial role in the control of the symptoms of PCOS. Low-dose contraceptive pills are recommended to restore menstrual regularity in PCOS women who do not wish to conceive. Other hormone treatments such as progesterone tablets may also be recommended to protect against cancer of the uterus. In women with excessive hair growth or severe acne, treatment with anti-androgens may be used.

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