New trends in induction of ovulation in patients with polycystic ovary syndrome
Youssef El-Sayed Ahmed Hashem;
Abstract
Polycystic ovary syndrome (PCOS) is one of the most common endocrinopathies, affecting 5–10% of women of reproductive age.
The evaluation of women with presumed PCOS desiring pregnancy should exclude any other health issues in the woman or infertility problems in the couple. Before any intervention is initiated, preconceptional counselling should be provided emphasizing the importance of life style, especially weight reduction and exercise in overweight women.
Treatment of adverse lifestyles, including obesity and physical inactivity, should precede ovulation induction.
Weight loss prior to infertility treatment improves ovulation rates in women with PCOS, but there are limited data that it improves fecundity or lowers pregnancy complications.
The ideal amount of weight loss is unknown, but a 5% decrease of body weight might be clinically meaningful.
Anovulatory infertility is associated with polycystic ovary syndrome (PCOS) in the majority of cases and it appears to be difficult to manage safely and successfully with OI drug therapy in this population. The reviewed evidence was obtained from randomized controlled studies of small to moderate sample size, short duration, and limited methodology. The investigators used different approaches, treatment protocols, study population, definitions of outcome measures and types of outcomes. The question on which is the safest and the most effective OI drug therapy in these women does not have a clear answer yet. According to the available evidence:
Clomiphen citrate (C.C) therapy remains the first choice of OI drug therapy because of its relative safety, effectiveness in achieving ovulation, simple mode of administration and relatively low cost. However, success in achieving ovulation equates with success in achieving pregnancy in only half of cases. The increased risk of multiple pregnancies associated with the use of CC should also be considered.
Aromatase inhibitors have been suggested as an alternative treatment to clomiphene as the discrepancy between ovulation and pregnancy rates with clomiphene citrate has been attributed to its anti-estrogenic action and estrogen receptor depletion. Letrozole, the most prevalently used antiaromatase for this indication, has been shown to be effective, in early trials, in inducing ovulation and pregnancy in women with anovulatory PCOS and inadequate clomiphene response.
Metformin as a pre-treatment and co-treatment with CC seems successful in increasing chances of achieving pregnancy in selected cases and has been proposed as a sequential treatment before the use of gonadotrophins. However, data regarding its use alone or as an adjunct to CC remain to be confirmed before recommending it as a standard therapy.
In women who do not ovulate or do not conceive in response to CC therapy, gonadotrophin therapy is the next medication of choice. It is still not certain whether any type of gonadotrophin preparations currently available is superior in terms of improving pregnancy rates and reducing complication rates. Low-dose gonadotrophin regimens (regardless of preparations used) may be considered in order to reduce the incidence of multiple follicle developments and the associated complications.
Oyulation induction (OI) drug therapy using gonadotrophins should be restricted to centers with the expertise and the equipment necessary to make appropriate clinical decision relating to the treatment and management of the associated complications.
Women with PCOS considering OI drug therapy to manage their anovulatory infertility should be aware that:
Regardless of the approach used, there appear to be at increased risk for multifollicular development and spontaneous abortion; the risk of developing serious complications such as multiple pregnancies and ovarian hyperstimulation syndrome appears to be higher when gonadotrophin therapy is used.
The evaluation of women with presumed PCOS desiring pregnancy should exclude any other health issues in the woman or infertility problems in the couple. Before any intervention is initiated, preconceptional counselling should be provided emphasizing the importance of life style, especially weight reduction and exercise in overweight women.
Treatment of adverse lifestyles, including obesity and physical inactivity, should precede ovulation induction.
Weight loss prior to infertility treatment improves ovulation rates in women with PCOS, but there are limited data that it improves fecundity or lowers pregnancy complications.
The ideal amount of weight loss is unknown, but a 5% decrease of body weight might be clinically meaningful.
Anovulatory infertility is associated with polycystic ovary syndrome (PCOS) in the majority of cases and it appears to be difficult to manage safely and successfully with OI drug therapy in this population. The reviewed evidence was obtained from randomized controlled studies of small to moderate sample size, short duration, and limited methodology. The investigators used different approaches, treatment protocols, study population, definitions of outcome measures and types of outcomes. The question on which is the safest and the most effective OI drug therapy in these women does not have a clear answer yet. According to the available evidence:
Clomiphen citrate (C.C) therapy remains the first choice of OI drug therapy because of its relative safety, effectiveness in achieving ovulation, simple mode of administration and relatively low cost. However, success in achieving ovulation equates with success in achieving pregnancy in only half of cases. The increased risk of multiple pregnancies associated with the use of CC should also be considered.
Aromatase inhibitors have been suggested as an alternative treatment to clomiphene as the discrepancy between ovulation and pregnancy rates with clomiphene citrate has been attributed to its anti-estrogenic action and estrogen receptor depletion. Letrozole, the most prevalently used antiaromatase for this indication, has been shown to be effective, in early trials, in inducing ovulation and pregnancy in women with anovulatory PCOS and inadequate clomiphene response.
Metformin as a pre-treatment and co-treatment with CC seems successful in increasing chances of achieving pregnancy in selected cases and has been proposed as a sequential treatment before the use of gonadotrophins. However, data regarding its use alone or as an adjunct to CC remain to be confirmed before recommending it as a standard therapy.
In women who do not ovulate or do not conceive in response to CC therapy, gonadotrophin therapy is the next medication of choice. It is still not certain whether any type of gonadotrophin preparations currently available is superior in terms of improving pregnancy rates and reducing complication rates. Low-dose gonadotrophin regimens (regardless of preparations used) may be considered in order to reduce the incidence of multiple follicle developments and the associated complications.
Oyulation induction (OI) drug therapy using gonadotrophins should be restricted to centers with the expertise and the equipment necessary to make appropriate clinical decision relating to the treatment and management of the associated complications.
Women with PCOS considering OI drug therapy to manage their anovulatory infertility should be aware that:
Regardless of the approach used, there appear to be at increased risk for multifollicular development and spontaneous abortion; the risk of developing serious complications such as multiple pregnancies and ovarian hyperstimulation syndrome appears to be higher when gonadotrophin therapy is used.
Other data
| Title | New trends in induction of ovulation in patients with polycystic ovary syndrome | Other Titles | الاتجاهات الحديثة في تحريض الإباضة بين مرضى متلازمة تكيس المبيض | Authors | Youssef El-Sayed Ahmed Hashem | Issue Date | 2013 |
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