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Polycystic Ovarian Syndrome (PCOS) affects 1 in
10 women of childbearing age and have important metabolic and reproductive
repercussion.[1] The treatment approach varies per
the age of the patient, desire for pregnancy and the presenting symptoms.
Approximately 80% of women who suffer from
anovulatory infertility have PCOS. The treatment approaches towards ovulation
induction varies per efficacy, patient BMI and other associated metabolic
abnormalities.
A recent paper published in the December issue
of Human Reproduction Update summarizes the evidence
based recommendations for the management of anovulatoryinfertility in
PCOS patients.[2]
The evidence will form the basis for WHO to
develop global guidelines. Management includes lifestyle changes,
pharmacotherapy, bariatric surgery and laparoscopic surgery.
Lifestyle management, weight loss and exercise
is recommended as the first line of treatment to improve general health and
decrease insulin resistance. Morbidly obsess women should seek expert advice.
At present, there is no evidence supporting the role of bariatric surgery in
PCOS associated infertility. [3]
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Clomiphene citrate is recommended as primary
agent to bring about ovulation. It is simple, inexpensive and induces ovulation
in 75% of the patients.[4] Letrozole, an aromatase inhibitor is
fast catching on clomiphene citrate as first place option.[5]
Metformin alone is not very effective in
improving the live birth rates. It is added to clomiphene citrate regimen in
older women with visceral obesity.
Gonadotrophins and laparoscopic ovarian drilling
are reserved as second line of treatment in patients who do not respond to
lifestyle modification and oral therapies. Gonadotropin releasing hormone
(GnRH) antagonist protocol is safe and combined with IVF. When GnRH agonist is
the choice for treatment, metformin should be used as an adjunct to reduce the
risk of ovarian hyperstimulation syndrome(OHSS).
Laparoscopic ovarian drilling is specifically
used when there are other indications for laparoscopic surgery. It should not
be used as first line of treatment. Concerns about long term effect of drilling
on ovarian functions are still unanswered. [6]
IVF can be of use in those patients who do not
respond to lifestyle modifications and oral ovulation induction drugs. It is
specifically useful in those patients who also have additional causes for
infertility.
No evidence supported the use of acupuncture or
herbal remedies in ovulation induction.
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