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Essay 264 - Sub-fertility

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		Posted by Elizabeth V. Fri Feb 22, 2008 12:11 pm
Explain to the couple that the reason for the subfertility is polycystic ovarian syndrome ,where the ovaries have multiple small follicles which fail to ovulate.Explaination should be in simple language . Absent or occasional ovulation is responsible for the menstrual irregularity such as oligomenorrhoea,amenorrhoea ,menorrhagia that she may be experiencing. Explain that the condition is aggravated by weight gain and that a reduction in weight therefore improves PCOS. Associated with decreased sensitivity of tissues to insulin and hence fasting insulin will be very high leading to aggravation of the condition. The excess of androgens that is present in the body partly due to production by the ovaries and partly due to peripheral conversion can lead to hirsuitism and propagation of the cycle by weight gain . These effects would translate into need for ovulation induction for pregnancy to occur and complications of ovulation induction such as multiple pregnancy and associated risk of increased perinatal morbidity and mortality,ovarian hyperstimulation syndrome. Pregnancy complications such as increased risk of miscarriage ,gestational diabetes mellitus,pre eclampsia . Long term effects include a 40% risk of NIDDM by the age of 40yrs and hence the need for regular GTT. Altered lipid profile and the risk of coronary artery disease.Yearly monitoring of the lipid profile can promote lifestyle and dietary changes. Unopposed estrogenic stimulus can lead to increased risk of endometrial cancer . Risk of ovarian cancer is also increased. Information leaflets and details of support groups are important, for the couple to come to terms with the condition. Treatment options depend on ruling out tubal pathology and semen analysis which I assume have been done in this couple. Treatment options include Weight reduction .A 5-10 % reduction in the weight is associated with return of normal menstruation and ovulation.It also improves the insulin sensitivity and exercise can improve th general fitness. Ovulation induction is another option. Clomiphene citrate or tamoxifen are used on day 2-day 7 of the cycle and act by increasing the gonadotrophin production and causing ovulation.Ovulation occurs in 75-85% with conception rates of 40-50%.This should be only undertaken in a set up with facilities for USS follicular tracking due to the associated risk of multiple pregnancy (5-10%) and OHSS.A maximum of 12 cycles are allowed without increasing the long term risk for ovarian carcinoma. 20 -30 % women will be resistant to clomiphene and benefit by the addition of metformin.Metformin increases the sensitivity of tissues to insulin and causes ovulation.Found to be of benefit when added to clomiphene in women with clomiphene resistance. Gonadotrophins for ovulation induction are needed in women not responding to clomiphene.Requires follicular tracking and is equally effective as laparoscopic ovarian drilling(LOD), although the miscarriage rates are higher (30- 40 % versus 14%).Routine use of gonadotropin releasing hormone analogues was not found to be of benefit and associated with increased risk of OHSS. LOD is associated with risk of laparoscopy such as visceral injury ,failure to gain entry into peritoneal cavity and the associated anaesthetic risk. However it has no risk of OHSS or multiple pregnancy.The pregnancy rates are 50 -70% with less chances of miscarriage when compared to gonadotropin induction.It also allows assessment of pelvis for other pathology such as endometriosis and the tubal patency.The effects last for 6-12 months
		Posted by Sarwat F. Fri Feb 22, 2008 03:11 pm
I will tell the couple that polycystic ovary syndrome is a condition in which there is hormonal imbalance in the body resulting in failure of release of eggs from the ovaries. This disease has short term and long term implications on the body. Short term effects include menstrual irregularities, hirsutism, infertility, miscarriages and oligomenorrohea. Long term implications include diabetes mellitus, dyslipidemia, hypertension, cardiovascular disease and endometrial carcinoma. However these clinical implications can be minimized or prevented by prompt treatment. Appropriate treatment is in accordance with the wishes of patients. Hormonal imbalance in polycystic ovaries leads to insulin resistance which can cause diabetes mellitus in the long term. Similarly it also leads to accumulation of lipids in the body that causes hyperlipidemia and consequently ypertension and cardiovascular disease. It is therefore advised that these women should have glucose tolerance test and serum lipid levels checked on annual basis by their GPs. Irregular menstruation and oligomenorrohea leads to thickened endometrium and there is a risk of endometrial hyperplasia and carcinoma. It is important to induce menstrual bleeding every 3 to 4 months by progesterones. There is controversy regarding risk of ovarian carcinoma with polycystic disease and it is still under research. Treatment options include measures like weight reduction, hormonal treatment like clomiphene, metformin and human menopausal gonadotropins to surgical procedure like laproscopic ovarian diathermy. Weight reduction is the first line management for polycystic ovary disease. Ideal body mass index is 18 to 23 kg/m2. it requires motivation on behalf of woman. In difficult cases or with morbid obesity, a referral to dietitian can be done. Clomiphene citrate is an antiestrogen which works at the level of pituitary to induce ovulation. It can be used in dose of 50 to 100 mg from day 2 to 6 of the menstrual cycle. A dose of 150 mg can be used in resistant cases. Ultrasound scan is done on day 10 to 14 to monitor the number of mature follicles. It causes ovulation in 80% woman and pregnancy in 40%. It is associated with certain complications which include hot flushes, breast discomfort, hair loss, visual symptoms and nausea. There is also a risk of multiple pregnancy with clomiphene for which follicular tracking is done. Next step of treatment is metformin which is a hypoglycemic agent and it corrects insulin redidtance in body leading to ovulation. It is given in dose of 500 mg three times daily. It has side effects related to gastrointestinal disturbances, nausea and diarrohea. It is free of risk of multiple pregnancies so follicular tracking is not required. It has the added advantage of correcting insulin resistance and therefore minimizing the risk of diabetes. In case of failure of treatment with either clomiphene or metformin, combination of two can result in ovulation and subsequent pregnancy. Next step of treatment is human menopausal gonadotrophins which is done in specialized fertility unit. It has the risk of multiple pregnancy of 10%. It is given in the form of injections. Follicular tracking is needed to monitor the number and size of follicle and for HCG administration. There is a risk of ovarian hyperstimulation syndrome of 1% which can be life threatening, although proper monitoring can minimize this side effects. Laparoscopic ovarian diathermy is the next step of treatment. It is as effective as HMGs but associated with complications of surgery and anaesthesia like bowel and blood vessel danmage. However it is free of risk of OHSS. It also gives the opportunity to check for any coexisting pelvic pathology like endometriosis and offer treatment. I will give written information to the couple and provide contact information of supporting organizations for polycystic ovary syndrome.
		Posted by Anna A. Fri Feb 22, 2008 08:01 pm
(a) What will you tell the couple about the implications of this diagnosis? [8 marks]. The couple should be explained carefully about the nature of her condition. This includes risk of her having irregular cycle with clinical symptoms of hyperandogenism. She should be made to understand that polycystic ovarian syndrome (PCOS) is associated with anovulatory menstrual cycle which leads anovulatory infertility. But she should be reassured that there are modality of treatment to overcome anovulation. She should be informed about long term risk of PCOS to her health status. This includes increased risk of cardiovascular diseases, hypertension and diabetes mellitus. Her risk of endometrial cancer is also higher (5 fold risk). She should understand that majority of PCOS patient has normal pregnancy outcome, but they have increased risk of having pregnancy induced hypertension and gestation diabetes mellitus. Her risk of having miscarriages is also high. She should be advised to practice healthy life style and maintain normal body mass index. Information leaflet and support group contact should be provided b. Critically evaluate the treatment options to enable this couple achieve a pregnancy [12 marks]. Diet program and weight reduction should be encouraged as reduction of 5-10% of her weight (if she is overweight or obese) is associated with resumption of ovulation and spontaneous pregnancy. Assuming that she had patent tubes with normal sperm count (her partner), Clomifene citrate should be offered first as it is simple to administer and it has less degree of ovarian hyper stimulation syndrome or multiple pregnancy as compared to gonadotrophin. Trans-vaginal scan (TVS) should be arranged for follicular tracking. Metformin is an insulin sensitizing agent and it has been shown to improve ovulation rate. Thus, it is prudent to start metformin for PCOS patient who known to have diabetes or insulin resistance. Side effect of metformin should be monitored. In a case of clomifene resistance, gonadotrophin therapy can be initiated. This requires close monitoring as it is associated with higher risk of ovarian hyper stimulation syndrome and multiple pregnancies. Surgical intervention in a form of ovarian drilling is associated with 80% of ovulation, 40-70% pregnancy rate and reduction risk of early miscarriages. It is also eliminate the risk of multiple pregnancy and ovarian hyper stimulation. Ovarian drilling is a laparoscopic intervention which may be hazardous in a patient who morbidly obese. Risk and complication of laparoscopic surgery should be discussed. In-vivo fertilization (IVF) may be offered if the previous discussed treatment failed. Information leaflet and support group contact should be provided.
		Posted by S M. Sat Feb 23, 2008 12:40 am
To start with, I will reassure the lady saying that polycystic ovaries are fairly common occurring in 20% of the population and half of these women have polycystic ovarian syndrome which is said to occur if polycystic ovaries are accompanied with signs of hyper androgenism demonstrated clinically and bio chemically. Having polycystic ovarian syndrome has far short and long term implications. The short term implications are anovulatory cycles which can lead to oligomenorrhea or amenorrhea. This can be associated with anovulatory infertility. Also women with PCOS can demonstrate feature of hyperandrogenism like acne, hirshutism and frontal balding. PCOS is associated with insulin resistance and obesity. If women do get pregnant, there is a risk of miscarriage and developing gestational diabetes. The long term consequences of having PCOS can be development of endometrial hyperplasia is regular withdrawl bleeds are not induce and subsequently a greater risk of endometrial cancer. Also obese women with PCOS are at a greater risk of developing type 2 diabetes mellitus at an earlier age than the average population. They are also prone to develop lipid imbalance, hypercholesterolemia and hypertension. However these can be prevented by maintaining BMI between 19-25 and diagnosed early by having regular withdrawl bleeds, GTTs and blood pressure checks. I will give written information to the patient. The treatment options would depend on the lady?s wishes, her BMI, the regularity of her cycles, whether or not she is ovulating and last but not the least on the semen analysis of the partner. If the lady is obese and not ovulating, just 5-10% decrease in her BMI can restore ovulation. For advice regarding weight loss, the lady can be referred to a dietician. Women can also be started on metformin as it is an insulin sensitizing agent. However it can give severe GI side effects. If she is not obese and still not ovulation she can be started on clomiphene with USS follicle monitoring in the first cycle. Clomiphene can induce ovulation in upto 80% of the women but has a pregnancy rate of only 40%. Its side effects include headaches, bloating, visual disturbances and even ovarian hyperstimulation in rate cases. Clomiphene can be combined with Intra Uterine Insemination if there is ovulation for 6 cycles but no pregnancy. If clomiphene fails to induce ovulation, it can either be combined with metformin for a few cycles or Laparoscopic Ovarian Drilling be offered to the patient or the lady be offered Super Ovulation using FSH and IUI. Laparoscopic ovarian drilling has been shown to be very effective in restoring ovulation but carries the risk of general anaesthetic and injury to internal organs and premature ovarian failure. SO IUI has good success rates too but carries the risk of Ovarian hyperstimulation and multiple pregnancy. If the above options fail, IVF should be offered to the couple. However this lady would be at a high risk of developing OHSS. Moreover IVF is readily available under the NHS with long waiting times for treatment. And private treatment can be expensive. If IVF fails or is refused, adoption can be discussed.
		Posted by rachael L. Sat Feb 23, 2008 03:45 am
a) Implications of a diagnosis of PCOS for future pregnancy include an increased risk of gestational diabetes and of pregnancy induced hypertension. Ovulation induction may be required to achieve pregnancy and this may result in multiple pregnancy . In the long term there is the risk of developing type 2 diabetes mellitus, hyperlipidemia and cardiovascular disease. If her periods are more than 3 months apart then there is also a five-fold increase in the risk of endometrial carcinoma and a 2-3 fold increase in the risk of ovarian cancer over the general population. I will reassure her that steps can be taken to minimise these risks and give information leaflets as well as document the discussion. b) Loss of 10% body weight if effective at inducing regular ovulation and will be advisable for obese or overweight patients before embarking on any assisted conception techniques. Clomiphene and tamoxifen will successfully induce ovulation in approximately 80% of patients with a 40-50% pregnancy rate. Clomiphene can be used for up to 12 cycles and there is no evidence that this increases long term risk of ovarian cancer. However it requires ultrasound facilities for follicular tracking and there is a risk of developing ovarian hyperstimulation syndrome (OHSS). Metformin is an effective therapy for ovulation induction with a much lower risk of OHSS and follicular tracking is not required. Recombinant FSH and human Menopausal Gonadotrophin (hMG) are of value in patients who have been resistant to clomiphene. There is a significant risk of OHSS particularly if used in combination with GnRH analogues. Follicular tracking is required. Laparoscopic ovarian drilling is effective at ovulation induction in 80% of patients with a 40-70% oregnancy rate, Risk of OHSS is minimal and so follicular tracking is not required. The duration of effect is 6-12 months. However this is an invasive procedure with attendant risks of general anaesthetic and laparoscopy. The long term risks including premature ovrian faiure are not clear. Laparoscopic ovarian drilling has largely replaced Ovarian wedge resection which is associated with significant adhesion formation.
		Posted by hoping .. Sat Feb 23, 2008 05:37 am
I would explain to couple that polycystic ovary syndrome is condition when ovaries have multiple small cysts because of arrested maturation of eggs along with altered hormone profile.This is likely to be responsible for her infertility.This can be asymptomatic or cause spectrum of chronic problems.Menstrual cycle can become irregular with prolonged intervals or absent. If interval between periods is more than 6 months for years then risk of cancer of womb increases due to endometrium not shed regularly.However this develops over years. It also causes altered metabolism due to insulin resistance which predisposes to Diabetes, hypertension and ischaemic heart disease over years.Partly this is due to increased tendency to gain weight as more energy is required to loose same amount of weight compared to women of similar body mass without polycystic ovaries. lack of binding protein for testosterone predisposes to developing increased hair growth over body and acne. If assisted conception is required then their is increased risk of hyperstimulation of ovaries which can be serious. Pregnancy can be natural or assisted but carries increased risk of misscarriage and development of diabetes in pregnancy. If her BMI is high then risk of other complications like hypertension, congenital anamolies in baby, operative delivery also increases. Treatment options include lifestyle modification especially if her BMI is high. Dietary modification including dietician review and excercise programme increase her chances of reducing weight.I will encourage her strongly with as loss of 5-10% of body weight leads to sponataneous return of ovulation and increases chance of conception. It will also improve success with assisted conception treatments and improves outcome of pregnancy.However this requires high levels of motivation and encouragement and support from care providers. Other option is ovulation induction with clompiphene citrate with followup ultrasound to avoid hyperstimulation.This carries 10% risk of multiple pregnancy and she should be counselled regarding this.There is also risk of other side effects particularly visual disturbance requiring treatment to be stopped.Moreover this cannot be given for more than 6 cycles as there is risk of ovarian cancer with prolonged use. If ovaries are resistant to clomiphene then ovulation induction can be acheived with gonadotrophin releasing hormone or ovarian drilling. Option should be decided in accordance with patient\'s wishes after considering risk benefit of both. Ovarian drilling avoids risk of hyperstimulation but involves operative risk of laparoscopy. IVF can be considered if inspite of ovulation pregnancy doesn\'t happen. IVF carries increased risk of multiple pregnancies and recently their have been concerns regarding intellectual deveopment of IVF born children.However it has 45% chance of pregnancy with each cycle.IVF using donor eggs can be considered but detailed counselling is required . treatment options should be disussed including increased risk of chromosomal problems at her age. Written information should be provided to couple and management planned considering thir wishes.
		Posted by Sahathevan S. Sat Feb 23, 2008 08:34 am
(a) What will you tell the couple about the implications of this diagnosis? [8 marks]. Poly cystic ovarian syndrome PCOS is a metabolic disorder associated with pituitary ovarian dysfunction. It refers to the presence of polycystic ovaries in women with a particular cluster of symptoms, which includes amenorrhea oligomenorrhoea, anovulation and subfertiliy and hyperandrogenemia which cause hirsutism, acne and crown pattern baldness. PCOS also associated with long term health problems of NIDDM, endometrial carcinoma and possibly ovarian carcinoma. Though subfertlity is problem in PCOS women spontaneous pregnancy still occur. Obesity is a common associated problem in PCOS women. If she is overweight, weight reduction is associated with a improvement in many symptoms of disorder. I will provide written information and support group details. (b ) Critically evaluate the treatment options to enable this couple achieve a pregnancy [12 marks] It is important that the patient optimizes her health before embarking on specific fertility therapy.The principle of management of anovulatory infertility in women with PCOS is to induce regular ovulation while minimizing the risk of multiple pregnancy and OHSS. Weight reduction is recommended as the safest means of inducing ovulation. She should aim for 5-10% weight loss. She should understand the adverse effects of raised BMI on pregnancy outcome and potential benefits of weight reduction. A Referral to dietician should be made. Her menstruation may become regular after significant weight reduction. She should keep a menstrual calendar in order to see the outcome.if menstruation are regular, day 21 progesterone should be investigated. If not pregnant after 6 months or unable to achieve weight loss, specific and effective approaches of induction of ovulation should be considered. First line treatment is clomiphene citrate. Patient should understand the possible Side effects such as hot flushes ,visual disturbances ,nausea ,vomiting and OHSS.Also she need ultrasound follicular tracking to monitor the risk of multiple pregnancy. If ovulation occurs with clomiphene but still not conceive after 6 months of treatment, she should be offered clomiphene stimulated intrauterine insemination. If there is no ovulation, she would be benefit with clomiphene and metformin as this has been shown to improve pregnancy rates in women with raised BMI. She should understand the side effect metformin which are Nausea, Vomiting, and GI Disturbances.Laparoscopy + ovarian drilling is second line treatment, risks of laparoscopy should be explained to her especially the risk relate to her raised BMI.The procedure is more intervetional and need general anesthesia ,complication includes visceral injuries ,periovarian adhesion and futher reduction in fertility. The benefit is that it is as effective as GnRH treatment, not associated with risk of multiple pregnancy and allows direct assessment of pelvic anatomy including tubal patency testing. If no response, GnRH ovulation induction with or without IUI or IVF. This has significant cost implications which should be explained to the couple. multiple pregnancy and ovarian hyperstimulation are the potential risk. I will provide written information. I would advice her to take folic acid. I would advice her to stop smoking and alcohol.
		Posted by Ritu J. Sat Feb 23, 2008 12:47 pm
A30 yr old partener have been referred to fertility clinic because of 2 yr history of subfertility.Woman is found to have polycystic ovary but no other abnormality.. What will you tell about implications of this diagnosis. a]I would tell her that it is a hormonal imbalance associated with short and long term implications. In this multiple small cyst are formed in ovary unable to mature to healthy follicle and ovulate.This is associated with oligoovulation and anovulation,hirsutism,prolonged cycles ,menorrhagia and subfertility.Obesity is frequently associated.Obesity , hirsutism and menorrhagia have impact on social llife as well. To achieve reproduction ovulation induction drugs ,laproscopy or IVF treatment may be needed. Long term implication is increased incidence of non insulin dependent diabetes by 40%.There is increased incidence of athrosclerosis,hyperlipidemia,sleep apnoea.cardiovascular diseases but it does not increase the mortality due to heart disease. It increases the incidence of endometrial hyperplasia and enometrial carcinoma due to prolonged estrogen exposure. Risk of ovarian cancer may be increased due to more than 12months use of clomiphene citrate,particularly borderline tumors. Increased risk of cancer has not been found though underlying associated factors like obesity and imcreased estrogen exposure is there. B]Critically evaluate the treatment options to enable this couple to achieve pregnancy. Weight reduction through diet and life style modification in obese woman is most valuable ,cheap and effective measure as it restores ovulation and fertility. Insulin sensitising agents like metformin , rosiglitazone though not liscenced for this use are next useful drugs to improve ovulation and fertility without increasing risk of cost of treatment,Ovarian hyperstimulation syndrome and multiparity.Rosiglitazone is associated ith liver toxicity,hence not used. Clomiphene citrate induces ovulation in 80% and pregnancy in 40%,cheap ,small risk of multiparity and associated with side effects like visual disturbances,hot ushes ,hypotension,headache. but concerns of increased risk of ovarian malignancy over 12 mths of use. Leterozole is another drug used for ovulation with minimum side effects and good results and no risk of OHSS. Low dose step up protocols are used for ovulation induction to decrease risk of hyperstimulation,costly method,increased risk of multiparity. Laproscopic drilling of ovaries is effective in upto 90%,gives opportunity for simultaneously correcting other pelvic pathology,corrects ovulation and fertility,no risk of OHSS and multiparity but risk of anaesthesia and surgery.
		Posted by Dr.Anies S. Sat Feb 23, 2008 04:22 pm
a.I will tell her that this is a common metabolic disorder affecting 20% of population.This is the likely reason for subfertility in them, due to anovulation.There are effective treatment available for anovulation. Spontaneous pregnancy may still occur if she ovulates. There is an increased risk of miscarriage, development of GDM and the likelihood of pregnancy induced hypertension during pregnancy. PCOS can lead to menstrual irregularities like Oligoamenorrhea, amenorrhea, menorrhagia or polymenorrhea. They may also have regular menstrual cycles. Obesity is another recogonised feature with this condition. It is difficult to access whether obesity is causing PCOS or vice-versa. I would also tell her that she may also develop acne, hirusutism, male pattern baldness. This is due to excess androgenic hormones. She may develop a hyper pigmentation(acanthosis nigricens) due to insulin resistence. PCOS is associated with long term implications to her health. 4o% of women develop NIDDM by the age of 40 years. They are also increased risk of developing cardio vascular problems and endometrial carcinoma. The possibility of ovarian cancer is also increased. I will provide the couple with information leaflets and address of the support groups. b. The options to this couple are conservative, medical and surgical treatment. Spontaneous pregnancy may occur. Most of the women are likely to have normal pregnancy outcome. If she is obese, weight reduction of 5 - 10 % is sufficient enough to achieve regular ovulation and spontaneous pregnancy. Weight reduction is also helpful in improving the general condition of woman and also reduces the risk of developing GDM. Ovulation induction can be done with clomephene citrate (an anti oestrogen). This achieves 70% ovulation rate with 40% pregnancy rates. She should have a regular follicular monitoring, as there is a risk of multiple pregnancy and OHSS. If no ovulation is observed with CC, combination of CC with metfomin is helpful to achieve ovulation and prgenancy. Metfomin is discontinued once pregnancy is confirmed. Metfomin is not yet licenced for this purpose in UK. If the women is ovulating, but fails to achieve pregnancy, intra uterine insemination of sperms are offered for atleast 6 cycles. But if the woman is CC resistant, the options are laparoscopic ovarian drilling(LOD) and induction with gonadotrophins. LOD is associated with 80% ovulation rate and 40 - 69 % of pregnancy rates. The miscarriage rate is 14% compared to that of 30 -40 % in gonadotrophin induction. LOD normalises the concentration of LH and serum androgens. There is no risk of multiple pregnancy and OHSS. Thus does not require follicular monitoring. As LOD is a surgical procedure, this is associated with complications of anesthesia and of laparoscopy.Even though the initial cost is higher,it is cost effective in the longrun. Gonadotrophin ovulation induction has a high risk of multiple pregnancy and OHSS, thus requiring folicular monitoring. Cost of treatment with gonadotrophin is higher compared to the others. If the couple still fail to achieve pregnancy, the last option is IVF with a success rate of 20-30%. The probability of success is better in the initial 3 - 4 treatment cycles. This procedure is associated with higher cost and requires intense hospital monitoring because of the risk of OHSS and multiple pregnancy. I will document the discussion in the case notes and allow the couple to make an informed choice. Information leaflets and address of support groups are also provided.
		Posted by Farina A. Sun Feb 24, 2008 03:46 am
The couple should be informed about the possible consequences of long standing PCOS, like that PCOS is related to insulin resistance and possible development of diabetes mellitus. Due to the abnormal lipid profile she is prone to develop hypertension in her future life and as a consequence to this she can have cardiovascular event. Hirsutism and its social impact are also important to discuss with the patient. One of the most important implications is the development of endometrial hyperplasia and carcinoma in a long standing disease. Sub-fertility is one of the issue, however it is amenable to treatment but patients suffering from PCOS are prone to miscarriages, gestational diabetes and hypertension. Patients should be provided with written information. If this patient is obese (BMI greater than 30), an advice for weight reduction is beneficial. treatment with metformin improves insulin resistance and there is some evidence that it improves ovulation. Metformin is associated with nausea and vomiting about which patient should be informed. Ovulation induction with clomiphine citrate in increasing dose is recommended along with follicular tracking. It is one of the effective ways of induction and have low incidence of ovarian hyperstimulation. There ia a small increase in risk of ovarian malignancy with its use. Risk of multiple pregnancies is slightly higher with this treatment. Clomiphine is associated with side effects of visual disturbances and hair loss. Ovulation induction with Tamorifen is less popular, however can be used for short term as long term use in breast cancer has shown to be related to endometrial hyperplasia and carcinoma. Laparoscopic ovarian drilling is one of the very effective way of ovulation induction in clomiphene resistant cases. It requires an anesthetic and expertise in laparoscopic surgery and poses the patient to the risk of anesthetic and surgical complications like injury to the bowel and vessels during entry, thermal injury to the surrounding structures during ovarian diathermy. There is no increase in risk of multiple pregnancy and intensive requirement of sonographic monitoring is not needed. Gonadotrophin induction of ovulation in clomiphene resistant cases needs patients compliance to repeated and timely injections, strict monitoring for follicular tracking using transvaginal ultrasound is required. Risk of ovarian hyperstimulation with or without pregnancy is higher with this treatment. . Multiple pregnancy is another important risk. When all the options fail, IVF can be a last resort. It poses the patient to the risk of ovarian hyperstimulation along with the risks of oocyte retrieval like infection, torsion and haemorrhage. However take home baby rates in PCOS is higher.
		Posted by yossef ibrahim E. Sun Feb 24, 2008 05:16 am
Dear sir\\ what is the appropriate monitoring to document ovulation in patients on clomid or GnRh for induction of ovulation.
		Posted by Idris O. Sun Feb 24, 2008 10:40 am
a)I would explain that polycystic ovary syndrome is the commonest endocrine cause of infertility. The cause is unknown but thought to be due to insulin resistance and hyperinsulinaemia. It has implications for fertility due to anovulation .Spontaneous pregnancy may still occur.There are effective treatment for anovulatory infertility.It also has implications for menses as anoulation is associated with amenorrhoea, oligomenorrhoea or polymenorrhoea. It causes hyperandrogeneamia leading to acne, hirsutism and hair loss. Weight gain may be a cause or effect of the disease. This may be associated with hypercholesteronaemia with increased risk of cardiovascular disease .If overweight, weight reduction improves many of the symptons of the disorder. Long term effects include NIDDM and endometrial carcinoma.They are also at increased risk of ovarian cancer. In pregnancy there is an increased risk of miscarriage, gestational diabetes and hypertensive disease.I would offer her information leaflet on PCOS and details of support group. b)Maintaining her BMI to below 30 is associated with regular ovulation and spontaneous pregnancy. This results in improvement in general health and reduction in the risk of GDM.This requires a lot of motivation and may be difficult to achieve. The medical method of ovulation induction with clomiphene citrate achieves ovulation in 70-85% of the patients and pregnancy rates are 40-50%. It is cost effective and monitored by follicular tracking with reduced risk of multiple pregnancy and OHSS. Is effectiveness is limited by its effect on the cervical mucus and the endometrium. Tamoxifen has equal effectiveness as clomiphene and little anti-oestrogenic side effects. Metformin is useful in correcting the hyperinsulinaemia associated with the disease and reduces the risk of miscarriage and GDM associated with the disease.It improves ovulation and pregnancy rates in obese patients when combined with clomiphene citrate. It has the side effects of nausea ,abdominal pain and diarrhoea. The Gonadodotrophins are useful in refractory anovulation. They have 80-95% ovulation rate and up to 30% pregnancy rate per cycle. The are limited because of high cost. They also require intensive monitoring due to the high risk of OHSS and multiple pregnancy. The Surgical treatment of anovulatory infertility is by ovarian drilling. This is suitable if failed medical treatment. It has the benefit of assessment of other factors in infertility like tubal infertility and adhesions. The ovulation rate is 70-90% and pregnancy rate is 40-69% with a low miscarriage rate of about 14% ( 30-40% for other methods). Regular period and spontaneous ovulation has been reported for many years after the procedure. This is because there is normalisation of serum androgens and SHBG over many years in over 60% of the patients.It has the additional benefit of no risk of multiple pregnancy, OHSS and no need for intensive monitoring. It is however, associated with the complications of lapararoscopy like uterine perforation, bowel and bladder injury. The long term effect of ovarian damage leading to ovarian failure or the risk of ovarian cancer is unknown. Other options of fertility would include IVF. This has a pregnancy rate of 15-25% per treatment cycle. There is however the risk of OHSS from hyperstimulated cycle with increased risk of multiple pregnancy. Another option is the use of donor oocytes. This has ethical issues and may not be acceptable to the couple. The last option is adoption.
		Posted by Shatha A. Sun Feb 24, 2008 05:16 pm
a) I will inform them that PCOS is a spectrum of diseases associated in addition to infertility with menstrual irregularity which range from oligomenorrhoea to amenorrhoea ,hirsutism due to hyperandrogenism , and obesity . this will cause long term health risk that will need management , and managment depend on the patient?s complaint. - In this patient induction of ovulations for treatment of Infertility will increase the risk of multiple pregnancy , this will increase the risk of prenatal morbidity and mortality , there is high risk of miscarriage and early pregnancy failure ,there is increase risk of gestational diabetes 13% compared to 10% in normal population it will need antenatal screening , also there is increase incidence of pregnancy induced hypertension . - Regarding long term implication there is high risk of type II diabetes mellitus specially if the woman is obese and there is family history of diabetes -There is high risk of cardiovascular disease due to abnormal lipid profile associated with the PCOS that will increase incidence of atherosclerosis and hypertension so fasting triglyceride , cholesterol and lipid profile should be done , but the mortality from cardiovascular disease was not found to be high. - Chronic anovulation associated with PCOS increase the risk of endometrial carcinoma 5 folds so gestagens should be offered to those with oligomenorrhea especially more than 3 months. - Risk of ovarian carcinoma 2.5 fold may be due to drugs used for induction of ovulation to treat infertility. Provide the couple with written information . b) -Before starting treatment tests for tubal patency and semen analysis should be done . the aim of treatment is induction of one follicle pre cycle to decrease risks associated with multiple follicular induction . -Decrease weight and adequate exercise as lose of 10% of body weight will restore ovulation in patient with PCOS in addition to normalise glucose metabolism and decrease risk of type II diabetes mellitus development in future. - Clomiphine citrate which is antiestrogen , block oestrogen receptors at hypothalamus and increase endogenous FSH will cause ovulation in 70-85% of patients with PCOS with pregnancy rate of 40-50% . its used from day 2-6 of the cycle and can be used up to 12 months , but should be used in place where there is facilities for follicular tracking by ultrasound. The women should be informed it will not increase the risk of ovarian carcinoma. - Metformin which is insulin sensitizer agent found to be increases ovulation rate if added to clomiphine citrate. And it was found that ovulation rate with clomiphine + metformine higher than clomiphine alone in those who are clomiphine resistant , it cause gastroenteritis side effects ,it will not cause weight changes . - Gonadotrophin therapy with the use of FSH recombinant or human menopausal gonadotrophine will induce ovulation in clomiphine resistant patients , there is a risk of multiple pregnancy and ovarian hyperstimulation and no much increase in conception rate. - Laparoscopic ovarian drilling (LOD) this can be offer to those with clomiphine resistant PCOS patients , done laparoscopically by laser or diathermy applied to the ovary using 40 watts ,4 sec. in 4 points for each ovary , its advantage that it induce ovulation in 80% of patients ,cause normalisation of LH secretion ,and pregnancy rate is 40-96% , there is no risk of multiple pregnancy or ovarian hyperstimulation , no need for follicular tracking ,also give a chance of laparoscopic visualisation of pelvic organs and doing tubal patency test . Its effective for 6-12 months . But there is a risk of laparoscopic surgery as invasive procedure , there is risk of peritubal adhesion ,and there is no clear evidence about possibility of premature ovarian failure due to ovarian damage. LOD replace old procedure wedge resection which is associated with adhesion
		Posted by K P. Mon Feb 25, 2008 01:56 am
I would inform her that this is a common condition and can be managed appropriately to improve outcome and prevent long term consequences. I will explain it is a condition which has a spectrum and women present with many different symptoms. Symptoms include irregular mestrual cycle, subfertility, symptoms of androgen excess like hirsutism and acne, and weight gain. I would explain to them that the diagnosis is based on her symptoms, blood tests and ultrasound findings. I would go on to explain that in her the reason for subfertility is anovulation secondary to PCOS and there are treatments for this. I would also inform her that there are risks associated with pregnancy. She is at increase risk for gestational diabetes and therefore would require screening and there is also a risk of pregnancy induced hypertension and preeclampsia, which would warrant increase vigilance. I would also explain that there are long term implications to this condition. She is at an increase risk of developing non insulin dependant diabetes mellitus, abnormal lipid profile. I would also explain that there is an increase risk of ovarian cancer and endometrial cancer however stress that the absolute risk is still very low. There is however no evidence of increase mortality from cardiovascular disease. I would emphasis the importance of a healthy lifestyle, good diet and regular screening to avoid these complications. I would provide written information and give her a leaflet regarding the condition. I would also give her information on available support groups. If she is overweight I would give her dietary advice and advice her to loose weight. I would recommend regular aerobic excercises. I would refer her to a dietician. I would explain that weight loss would help make her menstrual cycle regular and induce ovulation. Metformin is another option for overweight women. Although it does not cause weight loss, it reduces insulin resistance and increases the chances of ovulation. However it can be associated with gastrointestinal side effects like nause and diorrhoea which may lead to discontinuation. The NICE guidelines recommend clomiphene citrate as first line in women with anovulatory subfertility. It is given from Day 2 - 5 of the mesntrual cycle and is used for 6 months. It induces ovulation in 60 -80 % of women. However she should be warned of the risks of multiple pregnancy, and therefore attend ultrasound assessment at least after the first cycle for follicular tracking. There is also a risk of ovarian hyperstimulation syndrome. Next option is gonadotrophin analogues. These are given intramuscularly and therefore the woman might find it difficult to inject herself and find it uncomfortable. It is also associated with OHSS and multiple pregnancy and therefore would require an ultrasound assessment after the first cycle. If these methods fail, the next option laporoscopic ovarian diathermy. This causes a reduction in LH and androgen levels and induces ovulation in up to 80% of women. It is a efficacious as GnRH analogues. It is not associated with multiple pregnancies or OHSS. Another benefit of this method is that at laporoscopy the patency of the tubes can be checked and minimal endometriosis and adhesions can be removed, both of which can improve pregnancy rates. However risks of laporoscopy should be explained to the patient. These include risk of haemorrhage, infection, perforation of bowel, bladder or blood vessels, thrombosis and anaethetic risks. Finally if the above methods are not successful she can opt for invitro fertilisation.
		Posted by S M. Mon Feb 25, 2008 03:17 am
A 30 year old woman and her 35 year old partner have been referred to the fertility clinic because of a 2 year history of sub-fertility. The woman is found to have the polycystic ovary syndrome but there are no other abnormalities. (a) What will you tell the couple about the implications of this diagnosis? [8 marks]. (b ) Critically evaluate the treatment options to enable this couple achieve a pregnancy [12 marks]. a) I will tell the couple that polycystic ovary syndrome (PCOS) is a cause of anovulatory infertility. This means that it is a condition that can prevent the ovaries from ovulating. However, there are treatments that can be used to induce ovulation. When the woman conceives, the presence of PCOS will increase her risk of developing gestational diabetes. Outside of pregnancy she is also at increased risk of developing glucose intolerance and type 2 diabetes mellitus. PCOS can cause other metabolic changes. It can cause an increase in the level of triglycerides and LDL cholesterol which will put her at greater risk of atherosclerotic disease, hypertension and myocardial infarction. Also in the long term, the woman is at increased risk of developing endometrial hyperplasia and endometrial cancer. b) The treatment options can be divided into medical and surgical options. The first option for this couple is the use of clomiphene to induce ovulation. This is an effective treatment but has an increased risk of multiple pregnancy and ovarian hyperstimulation syndrome. Clomiphene can be used in combination with Metformin. PCOS is associated with high level of insulin resistance. Metformin functions to lower this resistance. After 6 cycles, if unsuccessful, gonadotrophins may be used to induce ovulation. Although effective they have a greater risk of multiple pregnancy and ovarian hyperstimulation syndrome. There use is also limited by side effects such as hot flushes and night sweats. Laparoscopic ovarian drilling is an effective surgical method of inducing ovulation. It is useful in the presence of clomiphene resitant PCOS. The advantages of ovarian drilling are that it does not cause ovarian hyperstimulation syndrome or increase the risk of multiple pregnancy. The disadvantages are that it carries the risks of laparoscopy such as risk of injury to blood vessels and haemorrhage; bladder or bowel injury. If laparoscopic ovarian drilling is unsuccessful, the next option would be in vitro fertilization (IVF). The success rate of IVF is 30%. It is limited by the side effects of the drugs used to stimulate the ovaries. Also the process of oocyte retrieval may be painful. If the couple have had children, then this will have to be done privately and is expensive.
		Posted by a P. Mon Feb 25, 2008 08:45 am
a.Polycystic ovarian syndrome is a combination of results as suggested by biochemical tests indicating hyperandrogenaemia, elevated luteinising hormone, suppressed sex-hormone binding globulin and polycystic ovarian morphology on ultrasound. Other features may include normal or raised body mass index, oligo/amenorrhoea or normal menses or normal ovaries. However, the key underlying abnormality leading to long-term health risk is insulin resistance-hyperinsulinaemia with normoglycaemia. There is a risk of developing gestational diabetes in pregnancy; and impaired glucose intolerance and type 2 non-insulin dependent diabetes in 1 in 5 to 1 in 10 of women in the late 30s early 40s. This may be independent of body mass index. There are also cardiovascular risks. The presence of raised triglycerides, total and low density lipoprotein cholesterol, obesity and hypertension increases the risk of cardiovascular disease although the mortality rate is not above that of the background population. The effect on high density lipoprotein is unclear. There is an association between oligo/amenorrhoea and endometrial hyperplasia and endometrial carcinoma. Hence, in the absence of attempting to conceive, the administration of regular progestogens to promote a regular withdrawal bleed is recommended. There is no increased risk of breast cancer in patients with polycystic ovarian syndrome. However, there may be an increase in recurrent miscarriage. Written information regarding explanation of the condition is given. b.Optimising management prior to conception involves a multidisciplinary approach. This includes maintaining or reducing weight (if appropriate) to a body mass index of 25. In the latter, this is by hypocaloric dieting and exercise which has been shown to result in resumption of ovulation and increase in fertility in anovulatory obese women with a normalisation of glucose metabolism. The above would involve referral to a dietician and either self or GP referral for a graded exercise programme. Urinalysis for glycosuria, fasting blood glucose with oral glucose tolerance test to exclude impaired glucose tolerance is arranged with referral to an endocrinologist as appropriate. Blood pressure to exclude hypertension is checked. A hysterosalpingogram for tubal patency is arranged under antibiotic cover to minimise pelvic infection. Semen analysis excludes a possible male cause for infertility. If the above are normal, options include monofollicular ovulation induction with oral clomiphene 50mg from days 2-6 of the cycle (may require withdrawal bleed if amennorhoeic) followed by an ultrasound scan to track follicular growth. Risks include visual disturbance necessitating therapy cessation and multiple follicular development and multiple pregnancy. No follicles may develop in which case the dose is increased to 100mg. Human chorionic gonadotrophin may be given to trigger ovulation if required. To minimise the possible risk of ovarian cancer, therapy is usually limited to 6 cycles. There is a 10-15% chance of conception. In the absence of response, low dose gonadotrophins may be used, but this involves daily injections and several blood tests with a 10-15% success rate. Metformin has been used successfully in pregnancy to reduce the incidence of gestational diabetes but is unlicensed and cannot be routinely recommended at present. Surgery involves laparoscopic ovarian drilling via diathermy or laser. This has shown a persistence in ovulation and normalisation of menses and endocrine profile in >60% of patients. However, the risks of general anaesthetic, visceral/vascular injury including ovarian atrophy and adhesions must be explained. If the above fail, referral for in vitro fertilisation may be appropriate. Written information is given outlining the benefits and risks of each option and the patient followed up in clinic as appropriate.
		Posted by Farkhanda A. Mon Feb 25, 2008 08:55 am
(a) I will inform the couple about the diagnosis and also reassure them that it is not an uncommon condition. Its incidence is about 20%. It has immediate and long term effects on women?s\' life. It causes anovulation due to multiple follicles grow, but no one grows enough to release egg. In this way it is responsible for anovulatory infertility. Due to decrease production of sex hormone binding globulin by liver and increase conversion of oestrogen, androgens levels become high which are responsible for acne, deepening of voice and abnormal hairs distribution on face and body. Pcos also causes increased resistance to insulin and disturbance in carbohydrate metabolism which is the reason for obesity. It cause derangement in lipids and ultimately hyperlipidaemia. Long term implications; pcos causes type 2 NIDDM , due to oligomenorric menstrual cycles, increased exposure of oestrogen to endometrium, risk of hyperplasia and cancer of endometrium. There is an increased risk of coronary heart disease due to the imbalance of lipids. (b) General advice about decreasing BMI. It can help in resumption of regular periods and ovulation. Medical treatment. Clomifen Citrate for ovulation induction. It is associated with multiple pregnancy, so follical monitoring by ultrasound is needed to avoid this complication. It is used for 12 months with a 6 monthly increase in dose with a blood test for progesterone level to check ovulation. It is associated with nausea, vomiting, blurring of vision, hair loss and constipation. Gonadotrophin releasing hormone analogue is another option for ovulation induction, but they are associated with multiple pregnancy, ovarian hyperstimulation and other side effects of hypooestrogen. Surgical treatments include:- Ovarian wedge resection which is not associated with multiple pregnancy, ovarian hyperstimulation but it can cause damage to the ovaries and adhesion formation. There are risks of anaesthesia and laparoscopy. More recent in practice is laparoscopically ovarian drilling. There are 4 points to diathermised by using 40 watts for 4 seconds. It is not associated with multiple pregnancy, OHSS. It lowers the androgens level, is more successful in achieving pregnancy in 6-12 months after the procedure. It put patients in extra risk of anaesthesia and laparoscopy. The last option is IVF (in vitro fertilisation). All this information should be documented and backed up by giving information leaflets.
		Posted by SUDHA N. Mon Feb 25, 2008 11:01 am
I will tell the couple that PCOS is present in 10% of women in the population and is the commonest cause of anovulatory infertility.In this disorder the eggs are unable to mature and hence ovulation does not occur.We do not know the cause of this disorder.Research has shown that it tends to occur in families and the insulin levels are high and there is insulin resistance.This upsets the hormone balance.These women show a symptom cluster of obesity(increased waist-hip ratio), irregular menstrual cycles , hirsutism and anovulation.Increased insulin resistance affects the glucose metabolism and lipid metabolsm.The long term consequences of this are Diabetes type2 which occurs in 20% in 10-15years.During pregnancy she will need screening for gestational diabetes.PCOS is associated with dyslipidaemia and is known to increase the triglycerides and cholesterol level , thus increasing the incidence of atherosclerosis and risk of hypertension and myocardial infarction.Women with oligomenorrhea or menstrual cycles spaced for more than 3months are at risk of developing endometrial cancer 5-6fold and ovarian cancer 2-3fold.She should be reassured that she can be treated for anovlation.She should be given written information and further clinic appointment should be made. b)This woman with subfertility has PCOS, assuming that her partner\'s semen analysis is normal and her tubes are patent, she should be considered for ovulation induction.She should be asked to lose weight.Losing 5-10% of weight helps in regulating the menstrual cycle and in spontaneously correcting ovulation.Clomifene citrate 100mgs is commenced from day2 of menstrual cycle for 5days.Follicle tracking is done on day10,12 to know the response and also because of the small risk of hyperstimulation.Clomifene can be given fo r12 cycles.If after 6 cycles she has not conceived then adding metformin helps.It decreases the insulin level and regulates the menstrual cycle and helps in induction.Human menopausal gonadotrophin or recombinant FSH can be considered.These women are at risk of developing ovarian hyperstimulation and multiple pregnancy, so need to be monitored.They should be educated on the early symptoms of hyperstimulation and 24hr telephone number should be given for them to contact the hospital.If this fails then she sshould be considered for laparoscopic ovarian drillingwith diathermy or laser(if available).It achieves ovulation in 80% and pregnancy rates of 40-60% with normalisation of LH.Does not require follicle tracking as stimulates only one follicle.The disadvantage is that it is invasive and the risks of laparoscopy , which may involve bowel or vessel injury.
		Posted by Dr seema jain J. Tue Feb 26, 2008 01:56 am
I?ll explain the couple that PCOS is predominantly a condition of male androgen excess and one of the commonest causes of anovulatory infertility. Failure of follicular maturation leads to anovulation. It is a familial condition influenced by environmental factors. Apart from subfertility, the hyperandrogenaemia can lead to symptoms like acne, hirsutism,menstrual irregularity & hairloss. Obesity is commonly associated with it. Hyperinsulinemia is considered to be the central factor in its pathogenesis. Spontaneous pregnancy is known to occur in women with PCOS though women with PCOS may face pregnancy related complications like miscarriage, pregnancy induced hypertension and gestational diabetes. I will reassure them that effective treatment for anovulation is available and with treatment the chances of success are high (almost 60 ? 70%). The longterm complication of PCOS include diabetes mellitus because of insulin resistance.Hyperlipidemia and abnormal glucose metabolism predispose these women to cardiovascular disease and hypertension.Endometrial cancer because of unopposed estrogen stimulation of endometrium ican occur. I will provide them with an information leaflet and guide them to support groups. It is not a curable disease but most of its symptoms respond well to drug therapy and it is important to treat it in view of its long term implications even if the woman is not bothered by the symptoms. Spontaneous pregnancy can occur and so the couple can be offered expectant management. Lifestyle changes (exercise & weight loss) form the mainstay of therapy. Weight loss 5 ? 10% can lead to ovulatory cycles in 40-50% cases.Adherence to a strict diet and exercise regimen may not always be possible and may add on to the stress of infertility. Ovulation induction with clomiphene citrate (50 mg D3 ? D7) can lead to ovulation in about 60-70% cases. A trial of upto 6 cycles can be given if ovulation occurs. Risk of multiple pregnancy (10 ? 20%) should be explained. The dose required for ovulation should not exceed 150-200 mg/day and if ovulation occurs at a lower dose,there is no need to increase the dose.. If there is no pregnancy following six ovulatory cycles with clomiphene citrate, further 3-6 cycles with IUI with clomiphene can be offered. Addition of insulin sensitiser (metformin) to clomiphene has shown to improve the pregnancy rates and is advocated when pregnancy does not occur with use of clomiphene.Clomiphene resistant cases or in women whom pregnancy has not occurred following use of clomiphene as above, the second line of therapy would be either use of gonadotropins or laparoscopic ovarian drilling. Ovulation induction with gonadotropin (preferable with FSH instead of HMG) is associated with almost 40-50% success rate but it also carries the risk of multiple pregnancy (20-30%) and OHSS. Th lowest possible dose of the gonadotropins should be used to minimise the risk of OHSS and multiple pregnancy. Laparoscopic ovarian drilling results in ovulatory cycles in upto 60-70% cases and the advantage is that the risk of OHSS and multiple pregnancy is minimised.Follicular studies may not be required. The risks inherent with laparoscopic procedure of visceral and vascular injury, formation of adhesions and decrease in ovarian reserve over a couple of years are its disadvantages. IVF can be offered if all the above treatment modalities fail. GnRH antagonist to prevent premature LH surge has shown promising results in PCOS women undergoing IVF. The couple should be offered the option of adoption if no pregnancy results with these measures.Under all circumstances the wishes of the couple should be known and they should be informed about all the possible options.Psychological counselling should be encouraged and referral to support groups done. A.
		Posted by yossef ibrahim E. Tue Feb 26, 2008 08:54 am
I would explain to the couple that this is a condition characterized by the presence of multiple ovarian cysts that do not ovulate.It is associted with anovulation and absent or infrequent menses.It is associted with hyperandrogenaemia causing acne,hirsutism and hair loss.It is the cause of their subfertility though spontaneous pregnancy may occur.I would explain the association with long term health sequalae .There is increased incidence of endometrial cancer especially if interval between menses is more than 3 months.There is increased incidence of cardiovascular disease due to abnormal lipid profiles.There is increased incidence of NIDDM which needs yearly screening. I would give written information. 5-10% weight loss may resume regular ovulation and improves endocrine profile. However,it is difficult to attain and requires motivation.Clomiphene citrate induces ovulation in ~80% of women with 40% conception rate over 6 cycles.However, it has side effects like visual disturbances,hot flashs and there is putative risk of developing ovarian cancer.Metformin is useful if the woman is obese ,it help facilitate weight loss and ovulation and provide beneficial metabolic effects.However,it has side effects like nausea and diarrhoea.Gonadotrophins have cumulative pregnancy rate of ~60% over 6 months.However, it is associated with risk of multiple pregnancy and OHSS.LOD has similar conception rates to those of gonadotrophins.There is no need for cycle monitoring,no increased risk of OHSS.However,it carries the risk of anaesthesia,visceral injuries and adhesions.IVF results on a per cycle basis are similar to the fecundability of natural conception in general population ~27%.THERE IS INCREASED RISK of multiple gestations and OHSS.I would give written information.
		Posted by yossef ibrahim E. Sat Mar 1, 2008 08:48 am
dear sir\\ you have deduced marks in my answer because i wrote the word association instead of implication.please can you look at q216 in the forum and explain to me the difference between my answer and your suggested answer to the first part of the questoin. secondly,you did not reply to my question about the appropriate method to document ovulation in patient on clomid or GNRH.
		Posted by yossef ibrahim E. Sat Mar 1, 2008 12:11 pm
Thank you sir for your immediate reply and clarification ,but for appropriate monitoring to document ovulation you have stated that ultrasound or hormonal [progesterone]can be used.please,again,look at q193 in your reply to ZAHARUDDIN,you stated that monitoring day 21 progesterone is inappropriate as it does not identify supraovulation. THANK YOU.
		Posted by Reena Jacob J. Sat Mar 15, 2008 01:31 pm
Implications Polycystic ovarian syndrome is a metabolic syndrome which causes stimulation of the ovaries,resulting in multiple small follicles as wellas hyperandrogenemia. This results in irregular cycles or amenorrhoea and anovulation. This condition has short term and long term implications. The short term implications include anovulation and subsequent subfertility. She mah have hirsuitism secondary to the hyperandrogenemia Obesity may be an association,though \'lean PCOS\'is also noted. In pregnancy,they may have increased risk of miscarriages due to luteal phase defects.She is also at higher risk of Gestational diabetes and hypertension in pregnancy A higher incidence of diabetes may be expected ,irrespective of her BMI. There is also an increased risk of hypertriglyceridaemia and hyperlipidaemia which increases her risks for cardiovascular events. She has an increased risk of endometrial cancer, and may be at a younger age There is also an ncreased risk of ovarian cancer The knowledge of these implications as well as the effect of hyperandrogenemia has psychological implications as well. Information leaflets should be given to her and also help her to get in touch with the support groups . Treatment Lifestyle modification and achieving an optimal BMI would be ideal. However,this is not easy to achieve. A 5-10% weight reduction will be beneficial and improve her chances with spontaneous ovulation. Ovulation induction with Clomiphene citrate may be attempted. 70-80% patients ovulate and 40% pregnancy may be achieved. However there is a risk of multiple pregnancy and hence follicular tracking is very important GnRH analogues may be used in Clomiphene citrate resistant cases. The risk of multiple pregnancy and OHSS is higher and also the side effects like hot flushes and weight gain etc may be intolerable in certain patients Laparoscopic ovarian drilling is an option and it has reduced risk of multiple pregnancy, however, it is invasive and has similar results as with GnRh analogues. Metformin may be used in combination with ovulation induction drugs and it improves the pregnancy rates,however the outcome and live birth rates is not significantly altered by its usage Intrauterine insemination and Invitro fertilisation are the other options in her. Success rates are in the range of 30-40% and there is a significant risk of multiple pregnancy and OHSS. Oocyte donation and adoption are the other options. Relegious issues and personal preferences play a part in this decision process