Dr Shosseini Taleghani hospital IVF centre winter 2015 INTRODUCTION Background Life style modification Induction ovulation Laparoscopic surgery IVF PCOS is the single most important cause of infrequent or anovulation ID: 931248
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Slide1
Infertility treatment in PCOS patients
Dr S,hosseini
Taleghani hospital , IVF centre
winter 2015
Slide2INTRODUCTION
Background
Life style modification
Induction ovulation
Laparoscopic surgery
IVF
Slide3PCOS is the single most important cause of infrequent or anovulationConstituting almost
40%
of cases of female infertility
Slide4The aim of treatment of infertility in PCOS:Successful induction of ovulation
without increasing the risks of multiple pregnancy or
ovarian hyperstimulation
Slide5Life style modification
loss of just
5 –10%
of body weight is enough to restore reproductive function in 55 within
6 months
of weight reduction.
should be the
first line
of treatment in obese women with anovulatory infertility associated with PCOS
Slide6moderate-intensity aerobic (endurance) physical activity for a minimum
of 30 min on 5 days each week
vigorous-intensity aerobic activity for a minimum of
20 min on 3 days each week
Exercise guidelines issued by the American College of Sports Medicine
Slide7clomiphene
Approximately,
75–80%
of patients with PCOS will ovulate after CC
conception rate of up to
22%
per cycle is widely accepted in those
ovulating
on CC
A maximum of
six cycles
is generally proposed, with a cumulative pregnancy rate of 50–60%.
Slide8The starting dose of clomiphene is 50 mg per day
starting on the
2nd to 5th
day of the menstrual cycle
The maximum recommended dose is
150 mg
per day
Treatment with clomiphene in women with PCOS is limited to
six cycles
(ovulatory)
Slide9Clomiphen resistence
: (ovulation failure)
extended use of clomiphene
glucocorticoids
pretreatment with
ocp
HCG
Slide10Aromatase inhibitor
Letrozole : 2.5 –5 mg per day for 5 days starting from any of Days 2 – 5of the cycle, which is similar to clomifene.
7.5– mg per day has been administered
5 mg per day would appear to be the optimal dose
Teratogen ?
Slide11Letrozole appears to improve live birth and pregnancy rates compared to clomiphene citrate
(the quality of this evidence was
low
)
OHSS was a very rare event, with no occurrences in most studies
Cochrane review,2014
Slide12metformin
ovulation induction: dose of 1500 – 2000mg per day in two or three divided doses
useful in patients with PCOS and a
normal BMI
(ESHRE) and (ASRM) guidelines 2013
Slide13the combination of metformin with clomiphene appears to be the best treatment
choice in patients with PCOS who are resistant to clomiphene ( before gonadotropin)
(ESHRE) and (ASRM) guidelines 2013
metformin’s potential to decrease miscarriage risk
??
Slide14the administration of metformin reduces the incidence and severity of OHSS when given to patients with PCOS who undergo multiple ovulation induction for IVFESHRE
guidline
2013
Slide15Gonadotrophins
Transient increase in FSH above a threshold dose for sufficient duration
Step-up regimens
Step-down regimen
Sequential step-up and step-down
regimen
Slide16monoovulatory
when a single follicle of 16 mm or higher was present with no other follicle 12 mm or higher
cycle cancellation is advised when more than
three
follicles of 16mm or larger were observed
10% multiple pregnancy rate after the use of
gonadotrophin therapy ?
Slide17Laparoscopic ovarian surgery
Surgical management of anovulation, especially in cases not responding to medical therapy
Making between
four to ten
punctures on the ovarian surface by diathermy or laser
Slide18Laparoscopic ovarian surgeryDepth of 4 -+ 10 mm on each ovary for a duration of 4 seconds each
Better success occurs in cases with:
high LH > 10 IU/L
short duration of infertility
normal BMI
Slide19There was
no evidence
of a significant difference in rates of clinical pregnancy, live birth or miscarriage in women with clomiphene resistant PCOS undergoing LOD compared to other medical treatments.
The reduction in
multiple pregnancy
rates in women undergoing LOD makes this option attractive.
Cochrane review 2012
Slide20IVF or IUI
PCOS in per se not an indication for IVF treatment, unless :
there is an associated cause of infertility
if the couple does not conceive despite six or more successful ovulatory cycles, that is, they also have an underlying element of unexplained infertility
Slide21IVF is a reasonable option, because the number of multiple pregnancies can be kept to a minimum bytransferring small numbers of embryos.