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.
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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