Lean CO how to treat

·         If  Testostrone  is high go for ovarian drillinIg, do 75gm GTT with 2hr insulin, if suggest hyperinsulinemia start metformin  in fact Metformin is seldom needed in thin PCOS as no hyperandrogenaemia induced by hyperinsulinaemia), Evaluation of insulin resistance not essential since management would’t change . Metformin no role in ovulation induction or additional use with clomiphene.

·         vit D3 however may given for at least 3 months before starting ovulation induction.

·         One should consider that the first step is withdrawal with progesterone.

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·         Then I would put her on cyclical OCPs (preferably with 3rd generation progesterone drospirenone) for 3 months (should bring down the high LH) along with Vitamin D3 & Myoinositol. Myoinositol. And vit D3. Later CC Yoga and walking

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Then after 3 months start ovulation induction with follicular monitoring, ovulation trigger with Recombinant low dose FSH works betterà HCG & advise timed relations.

Assess AMH- to avoid OHSS:-But AMH should be done as these patients are more prone to OHSS, clomiphene low dose meticulous monitoring and e2 levels or good Color USG. No necessity of Testosterone, Insuin tests.

Summary of lean PCOS: Usually with high LH & High AMH but normo insulinaemic:

Step-1- Withdrawal bleeding, & Vit D3, Exercise, Yoga. Myoinositol. Is really withdrawal bleeding essential? Though many are of opinion that there is no need for withdrawal before ovulation induction if endometrium less than 8 mm .On the whole, many  wouldn't give her OCP for not more than a cycle, and Metformin only  if stimulating for IVF. The intent is to try lower OHSS risk. Funnily, many may have poor quality oocytes

Step 2:- One or 3 cycles of OCP?  Three cycles of Diane/ DRSP, also be MPA for withdrawal followed by either direct ovulation induction or three months of OCPs followed by OI. is withdrawal with progesterone. Then I would put her on cyclical OCPs (preferably with 3rd generation progesterone drospirenone) for 3 months (should bring down the high LH) along with Vitamin D3 & Myoinositol. Then after 3 months start ovulation induction with follicular monitoring, ovulation trigger with hCG & advise timed relations. Simultaneously rule out male factor and later confirm tubal patency if no result with 3 cycles of OI. Ovarian drilling can be reserved for later in my opinion if LH stays high or OI fails.

Step3:-CC alone / combine gonadotrophin on day 9 of Menst cycle as per USG-daily r-FSH/alt day.   Baseline TVS on day 2, Clomiphene 50 mg day 2- 6, next TVS on day 9, if no follicle above 10 mm consider rFSH 75 IU. And then daily or alternate day TVS and FSH as per response.

If she becomes clomiphene sensitive, give her 4-6 cycles as previous.  The number of cycles that u want to carry on can depend on a woman's age , total duration of infertility and your agreement with the patient . In this case there is no hurrying

Consensus is to give 4-6 cycles of ovulation induction with clomiphene as first line, addition of metformin not necessary. Establish ovulation by monitoring 1-2 cycles

IVF: In Lean PCOS When? But at the end of 1-2 yrs many women may end up on IVF table, but with poor quality huge numbers of oocytes.

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·         Simultaneously rule out male factor and later confirm tubal patency if no result with 3 cycles of OI

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·         . Step 4:- Tubal evaluation would be helpful. If clomiphene resistant

·         Step 5:- If clomiphene resistant. Move to a gonadotropin or LOD based on patient profile and access to monitoring. Give 4-6 cycles of gonadotropin. Add IUI after 3 of the ovulatory cycles

·         Step 5 .Ovarian drilling can be reserved for later in my opinion if LH stays high or OI fails.

My concern is about metformin as she is lean even if insulin comes out to be normal. Wait for 3 months for spontaneous conception after LOD, then use clomiphene if she was resistant before and establish ovulation. If not, move to gonadotropins with or without IUI

 I too am not sure of using Metformin in lean PCOS.

Step 7:-Chronic low dose gonadotropin stimulation is the way forward if clomiphene resistant

 Metformin definitely has a role in improving insulin resistance in lean PCO

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Bhupesh Goyal   Thin PCOS. I suppose there won't be any features of hyperandrogenism as well as those of insulin resistance (acanthosis nigricans and acrocordons).

 In such a setting, I don't use metformin. As Dr Charu Rawat Mittal has lucidly stated, my approach will also be MPA for withdrawal followed by either direct ovulation induction or three months of OCPs followed by OI.

 Baseline TVS on day 2, Clomiphene 50 mg day 2- 6, next TVS on day 9, if no follicle above 10 mm consider rFSH 75 IU. And then daily or alternate day TVS and FSH as per response.

 Ovulation fulfills 2 Rotterdam criteria in the info provided.

PCOM exists which becomes PCOS with anovulatory cycles. Hyperandrogenism can be evaluated biochemically (free androgen index as baseline) .

Consensus is to give 4-6 cycles of ovulation induction with clomiphene as first line , addition of metformin not necessary . Establish ovulation by monitoring 1-2 cycles.

 Evaluation of insulin resistance not essential since management would’t change.

 Metformin no role in ovulation induction or additional use with clomiphene. Tubal evaluation would be helpful.

If clomiphene resistant . Move to gonadotropin a or LOD based on patient profile and access to monitoring. Give 4-6 cycles of gonadotropin a .

 Add IUI after 3 of the ovulatory cycles . Then move to further options after one year of no pregnancy with ovulatory cycles.

These are just guidelines. We need to modify as per our discussions with patient and circumstances

.What does Metformin does prior to IVF?  Metformin may be started without other indications if she is for IVF as it would lower the risk of ohss.

Role of OCP- one cycle prior to ivf but not to lower androgens or other reasons in a patient wanting to get pregnant. What does deranged FSH LH mean here? LH may add value to the diagnosis trigger at the appropriate time. I have no experience with myoinositol.

 Fulfills 2 Rotterdam criteria in the info provided. PCOM exists which becomes PCOS with anovulatory cycles. Hyperandrogenism can be evaluated biochemically (free androgen index as baseline).

Consensus is to give 4-6 cycles of ovulation induction with clomiphene as first line, addition of metformin not necessary. Establish ovulation by monitoring 1-2 cycles. Evaluation of insulin resistance not essential since management would’t change. Metformin no role in ovulation induction or additional use with clomiphene. Tubal evaluation would be helpful. If clomiphene resistant. Move to gonadotropin a or LOD based on patient profile and access to monitoring. Give 4-6 cycles of gonadotropin a. Add IUI after 3 of the ovulatory cycles. Then move to further options after one year of no pregnancy with ovulatory cycles. These are just guidelines. We need to modify as per our discussions with patient and circumstances. Metformin may be started without other indications if she is for IVF as it would lower the risk of ohss. Role of ocps one cycle prior to ivf but not to lower androgens or other reasons in a patient wanting to get pregnant. What does deranged FSH LH mean here? LH may add value to the diagnosis.

 Chronic low dose gonadotropin stimulation is the way forward if clomiphene resistant. She could be good candidate for LOD as well in that situation.

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 Wait for 3 months for spontaneous conception after LOD, then use clomiphene if she was resistant before and establish ovulation. If not , move to gonadotropins with or without IUI.

 If she becomes clomiphene sensitive, give her 4-6 cycles as previous 1st line.

 The number of cycles that u want to carry on can depend on a woman's age, total duration of infertility and your agreement with the patient. In this case there is no hurrying!

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 · Though many are of opinion that There is no need for withdrawal before ovulation induction if endometrium less than 8 mm .

 Achieved very good results with My inositol +Vit d3 and folic acid in such selected young, lean and thin PCO with short married life. Good counselling. No active tx with induction given.

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