Friday, 16 October 2020

How useful NAC in improving ovulation rate n PCO

 

Those with negative HOMA-index may be benefited by prescribing NAC rather than Metformin.

The choice of oral insulin sensitizers!!! Which agent as first line!!! A day may come when Metformin may be replaced by classical ISA (insulin sensitizing Agent) like metformin.

NAC has “Noninsulin-related mechanisms”

Is NAC going to replace traditional Metfromin in subfertile anovulatory women who exhibit hyperinsulinemia?? Which oral agent will be more effective in promoting fertility –Metformin or NAC??

Many feel that in Indian women many women do not respond to conventional Metformin. That is the experience of many of us . What to do in such subfertile women with impaired laboratory documented Carbohydrate metabolism? Should we jump to costly gonadotrophins keeping in mind that such PCOS women are ”Hyperinsulinemic PCOS” ??

Those patients may undergo HOMA test. Those with negative HOMA-index may be benefited by prescribing NAC rather than Metformin.

Why at all Metformin fails and become less successful? The explanation is that path of action at cellular level is absolutely different. The association NAC + Inositol + folic acid , regardless of insulin-resistance state, seems to improve ovarian function in PCOS patients. Therefore, inositol and NAC may have additional noninsulin-related mechanisms of action that allow achieving benefits also in those patients with negative HOMA-index.

Carry home message is :--Those with negative HOMA-index may be benefited by prescribing NAC rather than Metformin.

 What are the factors that can predict successful Ovulation induction & Prognosis of Oocyte quality. Forced Ovulation by any means do not equate with live baby rate. There may increased Miscarriage rate, karyotypic abnormality and other cog abnormality as a woman ages . Remeber this before you enrol your name for DM/ Ph D /FNB

1)                   Age:-  Most important predictor, Because the good quality ova are released in early part of life. After 35 yrs-biological aging of ova are immense and  besides  the age factor (biological clock) exposure to many deleterious toxic agents since childhood to her current age  do affect oocyte surrounded by follicular cells . Follicular cells do not any way protect the oocyte much for passage of pollutant particles be it food related / environmental toxins (automobile smokes in articular,. One solution is freezing the eggs.

2)                   BMI:-. Obese women are less fertile, One solution is freezing the eggs. both by natural methods & by OI, ; require higher dose of stimulation and more prone to miscarriage. Eighty per cent of obese women have IR & hyperinsulinaemia. Many have stigma of hyperandrogenism. More insulin à More LH secretion and decreases SHBG with resultant Free Testosterone conc.

 

3)                   Central Obesity & high BMI are major associations of IR & hyperandrogenism. There are two problems with Obese women A) in IR women:--They require higher dose of stimulation and B) In obese women: - If one initiates with low dose ten poor preg rate & increased misc rates. Even low dose Ry may cause multifollicular response, high Cycle cancellation rate, If one tries seriously it is not impossible to  lose wt of 10.2 Kg by 6 months!.  But a great motivation is required. Those who were able to lose wt the miscarriage rate will hopefully come  to  say 20%  from about  75% those who failed to lose Wt and insist to doctors it initiate  with Ov induction . Metformin, is now widely used in infertile women woman associated with PCOs particularly who are obese.

 

4)                   Smoking & Drug Abuse.  Effects of Pollution.

 

5)                   Decreasing seminal parameters with aged husband. Increased divorce rate is also an indication of late childbearing.

 

6)                   Lab aids to diagnose dwindling Ovarian Reserve (Impending POF). There are two tests (Static & dynamic). Static test implies age (independent predictor of for quality of oocytes & preg rate) whereas dynamic tests include AMH, AFC. Rising FSH (day 2) . These three test (dynamic) tests including poor response with high dose of gonadotrophins are indirect predictors of Ov reserve  but not quality of oocyte releases and therefore do not correlate with   preg rate. Clinically this (early dwindling ovarian function ) may be anticipated by frequent cycles due to decreasing conc of inhibin B (secreted by Primordial Follicle)-thereby rise of FSHà Rapid /augmented growth of Dev Foll—Rise of E2 and premature Luteinization & Polymenorrhoea.

 

Carry home message : Marry by 28 yrs and be mother / father by 30 yrs , Be merry at Doshera,

 

 

 

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