A 32-year-old nulliparous woman has long standing confirmed PCOS. when attending active she states that she intends to stop cocp to conceive. How would you proceed with her care?
A detailed history about the cycles before her COCP\'s whether spontaneous or induced, her LMP, how long she has been on COCP\'s, why was she started the type any conceptions prior to COCP\'s is asked. Sexual history about how stable her relationship with her partner is gently enquired. She is offered screening for sexually transmitted diseases and recommended rubella vaccination.
In general examination her BMI is calculated. If > 25 denotes obesity with higher probability of gestational diabetes and preeclampsia if she conceives. Sign of hyperandrogenization, excessive facial hair, body hair, noted. Sign of acanthosis nigricans, darkening hyperkeratosis, papillamatosis of axilla, nape of neck, flexures is observed. Her field of vision checked. Any thyromegaly or galactorrhoea are also noted. & Per speculum examination to rule out any cervical pathology and a pelvic examination to note the size, mobility of uterus ruling out fibroids or endometriosis. Any adnexal mass can also be felt.
I would now explain the implications of having polycystic ovaries and its effect on conception. This condition, which affects 10-20% of woman of reproductive age group. It is associated with anovulation clinical and biochemical evidence of hyperandrogenization. Since she was on COLP\'S which would reduce her LH levels. Thereby reducing her androgen levels, she will probably respond to treatment early. The is advised to reduce her weight stressing that spontaneous ovulation and menstruation occur with a 10% reduction of weight.
I would initially counsel her for a premenstrual diagnostic laparoscopy with ovarian drilling, with a tubal patency test done simultaneously. It has an ovulation of 80% and pregnancy rate of 40-70% with 14% miscarriage rates. The other advantages being ruling out endometriosis, & releasing nonvascular adhesions of present. The effect persists for a year. She is informed about the general anesthesia, complications of the procedure, and consent obtained.
The ovulation inducing antistrogen clomiphen 50 mg / day from 2 to the 6th day can be given which increases the FSH and LH levels. Quotation of 80% with a pregnancy of 40% achieved. In this can be given upto 12 cycles. The controversial opinions about the risk of ovarian cancer are explained. In clomiphen resistant patients ovulation induction with gonadotrophins offered. However this has higher complication of multiple pregnancy and ovarian hyper stimulation syndrome. As she is 32 years the rate of spontaneous ovulation decreases by 35 years. She is also unformed about the option of IVF its success rate and the cost faction associated with it.
