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Pcos, Infertility

The patient is a 25-year old woman presenting with primary infertility for 4 years and irregular menstrual cycles since menarche. She exhibits signs of hyperandrogenism. The diagnosis is polycystic ovarian syndrome (PCOS) causing anovulation and infertility. Workups aim to evaluate hormonal and metabolic factors. Treatment focuses on lifestyle changes, medication to regulate cycles, and ovulation induction initially with clomiphene citrate. PCOS poses risks during pregnancy as well.

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66 views

Pcos, Infertility

The patient is a 25-year old woman presenting with primary infertility for 4 years and irregular menstrual cycles since menarche. She exhibits signs of hyperandrogenism. The diagnosis is polycystic ovarian syndrome (PCOS) causing anovulation and infertility. Workups aim to evaluate hormonal and metabolic factors. Treatment focuses on lifestyle changes, medication to regulate cycles, and ovulation induction initially with clomiphene citrate. PCOS poses risks during pregnancy as well.

Uploaded by

jayinthelongrun
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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INFERTILITY

a. Ovulatory Disorders – PCOS, Hyperprolactinemia, Secondary amenorrhea (Hypogonadism),


Premature Ovarian Failur/Insufficiency
b. Uterine Abnormalities – congenital uterine anomalies; uterine masses: myoma; endometrial
masses, cervical factors
c. Tubal Dysfunction – tubal adhesions from endometriosis or infection; clubbed fallopian tubes
d. Male factor infertility – semen analysis

PCOS/ INFERTILITY
25 year old nulligravid, consulted your clinic for primary infertility for 4 years. She has irregular
menstrual cycles since her menarche at age 10. She has no medical problems. Vital signs are stable.
BMI = 27. There is evidence on PE of fine hair growth above the upper lip and axillary area.

Diagnosis? Pathophysiology? Work-ups? Treatment?

Diagnosis is PRIMARY INFERTILY; POLYCYSTIC OVARIAN SYNDROME


Pathophysiology:
1. Primarily an intrinsic ovarian problem (excess ovarian production of androgens)
2. Hypothalamic-pituitary dysfunction (exaggerated gonadotropin releasing hormone pulsatility
resulting in hypersecrestion of LH) or adrenal dysfunction (excess adrenal androgen production)
3. METABOLIC (most widely accepted) – peripheral insulin resistance with consqequent
compensatory hyperinsulinemia. Hyperinsulinemia stimulates both ovarian and adrenal
androgen directly and suppresses sex hormone binding globulin synthesis in the liver, resulting in
an increase in free, biologically active androgens. Excess in androgen production casuses
premature follicular atresia and anovulation.

Work-ups:
Pregnancy test – always rule out pregnancy (patients with AUB, amenorrhea)
FSH, LH
Serum androgen (Dehyroepiandrosterone sulfate or DHEAS) and 17-OH-progesterone (congential
adrenal hyperplasia), testosterone, prolactin – to rule out other causes of androgen excess and
anovulation
75 g OCTT, Lipid profile – since patient is overweight, to screen for metabolic syndrome
Transvagial Ultrasound – to check for polycystic ovaries, as well as other anatomic abnormalities that
may be a cause of infertility
Semen analysis – for male infertility factor

Treatment:
*Abnormal cycles – combined oral contraceptive pills (containing antiandrogenic progesterone ie
cyproterone), cyclic progestins (MPA on days 16-25 of cycles) to regulate menses
*Infertility
1. Maintain BMI at 20-25
2. Weight loss especially in obese women. Exercise and caloric restriction.
3. Clomiphene Citrate - for induction of ovulation; 1 st course- 50 mg x 5 days starting on the 5 th day of
menses, or anytime if there is amenorrhea. 2nd course – 100 mg per day x 5 days, may be repeated for 2
additional cycles; MAXIMUM: 6 cycles. (Warnings: may cause multiple pregnancy, OHSS ovarian
hyperstimulation syndrome)
4. Metformin – 500 mg BID then 850 mg BID then TID; may be added to clomiphene
5. Gonadotropins or Laparoscopic ovarian drilling – second line if there is clomiphene failure (only by
REI specialist)
*Hyperandrogenism – Spironolactone, OCP with cyproterone
*If there is abnormal uterine bleeding: Endometrial biopsy should be done if ES > 10mm on day 6-10,
with hyperisulinemia; prolonged oligo- or amenorrhea who is older than 35 years old

**ADOLESCENTS – alternative method for diagnosis in adolescents:


At least 4 out of 5 of the following:
1. Oliogomenorrhea or amenorrhea 2 YEARS after menarche
2. Clinical hyperandrogenism – persistent acne and severe hirsutism
3. Biologic hyperandrogenism – plasma testosterone > 50ng/dl, increased LH/FSH ratio >2
4. Insulin resistance/hyperinsulinemia – acanthosis nigricans, abdominal obesity, glucose
intolerance
5. PCO on ultrasound

Treatment goals in adolescents: prevention of long term sequelae of anovulation and hyperinsulinemia
– lifestyle modification for obese, metformin; treatment of acne and hirsutism and regulation of menses
with OCPs

**PREGNANT WOMEN
There is increased risk for spontaneous abortion, or complications if pregnancy continues
Higher tendency for preeclampsia and GDM
Risk for preterm delivery
Metformin is safe for pregnancy

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