Title: Assisted Reproduction in the Treatment of Polycystic Ovary Syndrome
1 Assisted Reproduction in the Treatment of
Polycystic Ovary Syndrome
- By
- Ayman Nady Abdelmeged
- M.D.
- Lecturer of Obst. Gyn.
- Minia University, Egypt.
- anady_at_repromed.ca
2Introduction
- Polycystic ovarian syndrome (PCOS) is the
most common endocrinopathy among reproductive age
women - (Carmina and Lobo,1999).
3Definition
- Two of the following three features are present,
after exclusion of other etiologies - (i) Oligomenorrhoea and or anovulation
- (ii) Hyperandrogenism and/or hyperandrogenemia.
- (iii) Polycystic ovaries (sonar).
- (Rotterdam ESHRE/ASRM 2004)
4Phenotypes of PCOS
- 1. PCOS with PCO
- PCO hyperandogenism anovulation.
- PCO anovulation.
- 2. PCOS without PCO
- hyperandogenism anovulation.
- 3. PCO without PCOS.
- ( Isolated PCO Asymptomatic PCO ).
- (Azziz et
al.,2006)
5Incidence
- Epidemiological studies suggest that
approximately 4-7 of reproductive age women
have PCOS and 16-25 of an otherwise normal
population have isolated polycystic ovarian
morphology (PCO) on ultrasound (Polson et
al.,1998).
6- Various interventions have been proposed
ranging from life style modifications,
administration of clomiphene citrate, insulin
sensitizing agents,gonadotrophins and GnRH
analouges,the use of laparoscopic ovarian
drilling and assisted reproductive techniques. - (Thessaloniki ESHRE/ASRM,2008).
7Preprocedural Considerations
- Endometrial Neoplasia
- Insulin Resistance
- Metabolic Syndrome
- Weight loss
8Endometrial Neoplasia
- Chronic anovulation associated with PCOS may
lead to endometrial hyperplasia and sometimes to
frank endometrial cancer (Meier and
Schenker,1996).
9Insulin Resistance
- Insulin resistance is now accepted as one of
the integral components of PCOS . Insulin
resistance is associated with hyperandrogenic
symptoms and resistance to ovulation - inducing
agents. (Nestler et al.,2002).
10Diagnosis of Insulin Resistance
- Fasting glucose/insulin lt 4.5.
- Fasting insulin gt 24 µ IU/ml.
- One hour insulin post OGTT-75 gm gt 150 µ IU/ml.
- (Baillargeon and Carpentier,2007).
11IR (The Central Paradox)
12Diagnostic criteria for metabolic syndrome
- Diagnosis is made when 3 or more of
- these risk criteria are met
- ? Glucose 6.1 mmol/l
- Waist circumference 88 cm.
- ? HDL-C 1.3 mmol/l
- ?BP 130 / 85 mm Hg
- ?TG 1.7 mmol/l
- (Shroff et
al.,2007)
13Weight Loss
- Success of assisted reproduction has been shown
to decrease with increasing body mass index (wang
et al.,2000). - Weight loss has been shown to improve the outcome
of all forms of infertility treatments, including
IVF (Clark et al.,1998).
14Ovulation rate for obese versus non obese women
(Mulders et al.,2003)
15Effect of weight loss on PCOS (Tarlatzis and
Fauser,2008)
16Treatment options for PCOS
- 1. Clomiphene citrate
- 2. Insulin sensitizing agents
- 3. Aromarase inhibitors
- 4. Laparoscopic Ovarian Surgery
- 5. L.O.D versus gonadotrophins
- 6. Recombinant FSH versus urinary Gonadotrophins
- 7. Step-up versus step down protocols
- 8. GnRH agonist versus antagonist
- 9. In vitro maturation of oocytes
171.Clomiphene citrate
(Imani et al.,2002)
18 2.Insulin sensitizing agents in PCOS
(Legro et al.,2007)
19 3.Aromarase inhibitors in PCOS
(Polyzos et al.,2008)
204.Laparoscopic Ovarian Surgery
(Gomel and Yarali,2004)
21A) L.O.S versus gonadotrophins (live birth rate)
(Tarlatzis and Fauser,2008)
22 B) L.O.S. versus gonadotrophins (multiple
pregnancy rate) (Tarlatzis
and Fauser,2008)
235.Recombinant FSH versus urinary Gonadotrophins (
van Wely et al., 2003)
246.Step-up versus step down protocols in PCOS
(Messinis,2005)
257.GnRH agonist versus antagonist in PCOS
(Griesinger,2006)
26A) Duration of stimulation
27B) Gonadotrophin Consumption
28C) Number of cumulus-oocyte complexes
29D) Clinical pregnancy rate
30E) Ovarian hyperstimulation syndrome incidence
318.A)IVF versus ICSI in sibling oocytes from PCOS
patients (Hwang et al., 2005)
32B)IVF versus ICSI in sibling oocytes from PCOS
patients (Hwang et al., 2005)
33C) Embryo quality and development in PCOS
(Hwang et al., 2005)
34D) Results of assisted reproduction in
PCOS (Urman et al.,2004)
35E) Clinical IVF outcomes in PCOS
(Heijnen et
al.,2006)
369.In vitro maturation of oocytes
(Zhao et al., 2008)
37 9.In vitro maturation of oocytes
(Zhao et al.,2008)
38Conclusions
- Evaluation of women with presumed PCOS should
exclude any other health issues. - Preconception counseling regarding life style,
weight reduction, smoking and alcohol
consumption. - IVF is a third line treatment for PCOS patients
after failure of ovulation induction and LOS.
39- More patient tailored approaches should be
developed for ovulation induction. - Outcome of assisted reproduction in PCOS patient
is similar to matched controls treated for other
indications. - Metformin use in PCOS should be restricted to
women with glucose intolerance.
40- Insufficient evidence is currently available to
recommend the clinical use of aromatase
inhibitors for routine ovulation induction. - Even singleton pregnancies in PCOS are associated
with increased health risk for both the mother
and the fetus. - IVM of oocytes may in future become the first
line treatment.
41THANK YOU