Consensus on infertility treatment related to polycystic ovary syndrome

Abstract

The treatment of infertile women with polycystic ovary syndrome (PCOS) is surrounded by many controversies. This paper describes, on the basis of the currently available evidence, the consensus reached by a group of experts regarding the therapeutic challenges raised in these women. Before any intervention is initiated, preconceptional counselling should be provided emphasizing the importance of life style, especially weight reduction and exercise in overweight women, smoking and alcohol consumption. The recommended first-line treatment for ovulation induction remains the anti-estrogen clomiphene citrate (CC). Recommended second-line intervention, should CC fail to result in pregnancy, is either exogenous gonadotrophins or laparoscopic ovarian surgery (LOS). The use of exogenous gonadotrophins is associated with increased chances for multiple pregnancy and, therefore, intense monitoring of ovarian response is required. LOS alone is usually effective in <50% of women and additional ovulation induction medication is required under those circumstances. Overall, ovulation induction (representing the CC, gonadotrophin paradigm) is reported to be highly effective with a cumulative singleton live birth rate of 72%. Recommended third-line treatment is in vitro fertilization. More patient-tailored approaches should be developed for ovulation induction based on initial screening characteristics of women with PCOS. Such approaches may result in deviation from the above mentioned first-, second- or third-line ovulation strategies in well-defined subsets of patients. Metformin use in PCOS should be restricted to women with glucose intolerance. Based on recent data available in the literature, the routine use of this drug in ovulation induction is not recommended. 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.

The polycystic ovary syndrome: a position statement from the European Society of Endocrinology

“…Diet and lifestyle " Weight reduction alone may result in spontaneous ovulation in overweight or obese women with PCOS, and it is recommended that diet and lifestyle changes (including increasing daily exercise) should be the first-choice treatment in overweight and obese women with PCOS (211,272). Even in women who do not ovulate spontaneously following weight reduction and lifestyle modifications, the response to induction of ovulation is likely to be improved by these measures, although there have been reports of pregnancies after nine or more months of treatment (273).…”

“…It is wise to monitor the first cycle of treatment using ultrasound scans so that the dose can be adjusted if there is no response (or if too many follicles develop). If ovulation is successfully induced, it is conventional to continue treatment with CC for up to 6-12 months (272). A more recently proposed alternative to CC or other antioestrogens are aromatase inhibitors.…”

Polycystic Ovarian Syndrome Trend in a Nutshell

“…The second line of treatment was then exogenous gonadotropins and insulin sensitizers such as metformin, biguanide and thiazolidinedione. The other recommended treatments were surgical procedures such as laparoscopic ovarian surgery (LOS) and assisted reproduction techniques (ART) such as invitro fertilization and homologous artificial insemination (44,45).…”

Treatment Modalities for Infertile Patients with Polycystic Ovarian Syndrome

“…Selanik çalışma grubunda varılan konsensusa göre kilonun %5 azaltılması durumunda klinik bir anlam kazanıla-bilinecektir denilmiştir. 9 Bir Cochrane verilerini inceleyen yazıda da total vücut ağırlığının %5-10 azaltılması klinik ovulasyon sağlaması ile beraber şeker tolerans bozukluğunun ve metabolik sendrom bulgularında iyileşmelere sebep olduğu bildirilmiştir. 10 Diyet tek başına kilo verdirmek yerine egzersiz yapmak da ovülasyona yardımcı olabilirken ayrıca da insülin resistansını da azaltmaktadır, fakat egzersizin uzunluğu, tipi ve sıklığı hakkında tam bir karar verilemediğinden bu konuda yapıla-cak çalışmalara ihtiyaç vardır.…”

“…Yine de 2008'de Selanik Çalışma Grubunda varılan konsesusa göre CC ye metformin eklemenin bir avantaj sağlamadığı bildirilmiştir. 9 Çalışmalar Metforminin gebelikte kullanımı hakkında olumsuz etkilere sahip olmadığını göster-mekle beraber yine de kullanıp kullanmayacağı sorumluluğu primer hekime kalmaktadır.…”