Ovulation induction in women with polycystic ovarian syndrome: still steps to take

Abstract

We read with interest the clinical opinion paper on ovulation induction in women with polycystic ovarian syndrome (PCOS).1Bhagavath B. Carson S.A. Ovulation induction in women with polycystic ovary syndrome: an update.Am J Obstet Gynecol. 2012; 206: 195-198Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar PCOS remains an enigma in which the abnormalities in extra- and intra-ovarian factors exert a negative impact on the level of oocyte and embryo.2Qiao J. Feng H.L. Extra- and intra-ovarian factors in polycystic ovary syndrome: impact on oocyte maturation and embryo developmental competence.Hum Reprod Update. 2011; 17: 17-33Crossref PubMed Scopus (266) Google Scholar We wish to highlight some points on the topic. First, the data presented pertain to current aspects based on existing evidence; the clinical information derived from it can easily be applied by a general practitioner and not necessarily an expert in the field. Sufficient evidence on the treatment of PCOS with gonadotrophins is lacking though. Low-dose regimens have been suggested to ensure a limited number of follicles, resulting in monofollicular ovulation, pregnancy, and multiple live birth rates of 70%, 20%, and 5.7%, respectively.3Giudice L.C. Endometrium in PCOS: implantation and predisposition to endocrine CA.Best Pract Res Clin Endocrinol Metab. 2006; 20: 235-244Abstract Full Text Full Text PDF PubMed Scopus (240) Google Scholar Of note, intense ovarian monitoring is required to reduce complications and secure efficiency. In addition, in cases of associated male infertility factor or unsuccessful ovulation induction, intrauterine insemination accompanying ovulation induction is a reasonable alternative treatment option3Giudice L.C. Endometrium in PCOS: implantation and predisposition to endocrine CA.Best Pract Res Clin Endocrinol Metab. 2006; 20: 235-244Abstract Full Text Full Text PDF PubMed Scopus (240) Google Scholar not mentioned by the authors. Second, we propose that additional emphasis be given to the importance of the alteration in the endometrial level as it constitutes a critical factor leading PCOS patients to lower implantation and higher miscarriage rates. Elevated estrogen, insulin, free insulin-like growth factor 1, and androgens, together with obesity, have also been suggested to contribute to these undesirable outcomes.4Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop GroupConsensus on infertility treatment related to polycystic ovary syndrome.Hum Reprod. 2008; 23: 462-477Crossref PubMed Scopus (439) Google Scholar Unfortunately, endometrial status is overlooked in PCOS patients, as infertility in these women is mainly due to lack of ovulation and subsequently, induction of ovulation becomes the main clinical target and interest of research. Third, we would like to propose the following treatment modality: that of dexamethasone addition as cotreatment during ovulation induction with gonadotrophins. Data are scarce. The rationale behind this is that it can suppress or temporarily reduce the underlying factors mentioned above that contribute to the pathology of the syndrome. Interestingly, authors cite a Cochrane review on the addition of the substance, but to clomiphene, resulting in rising pregnancy rates.1Bhagavath B. Carson S.A. Ovulation induction in women with polycystic ovary syndrome: an update.Am J Obstet Gynecol. 2012; 206: 195-198Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Finally, we need to question if an appropriate strategy might be formulated so that these patients can be enrolled to in vitro fertilization more quickly, to avoid multiple pregnancies through elective embryo transfer strategies. More importantly, we maintain that research has to focus on and elucidate the molecular mechanisms involved not only in ovulation, but also in endometrial health in PCOS subfertile women, given the close functional association between the two. Ovulation induction in women with polycystic ovary syndrome: an updateAmerican Journal of Obstetrics & GynecologyVol. 206Issue 3PreviewInfertility is frequently caused by anovulation. The affected women present with irregular menstrual cycles and the most common diagnosis is polycystic ovary syndrome. Ovulation induction is commonly used to treat these women. Clomiphene citrate (a selective estrogen receptor modulator or SERM) remains the most used medication for treating this condition. Alternatives that have been used include other SERMs such as tamoxifen, aromatase inhibitors, insulin sensitizing agents, and ovarian drilling. Full-Text PDF ReplyAmerican Journal of Obstetrics & GynecologyVol. 207Issue 2PreviewWe thank Dr Siristatidis and colleagues for their interest in our clinical opinion on ovulation induction in polycystic ovary syndrome and for taking the time to raise interesting questions. This opinion was specifically directed at helping general obstetricians and gynecologists and not at the specialist reproductive endocrinology and infertility specialist. However, we have highlighted the potential complication and strategies to reduce multiple pregnancies under “Complications of ovulation induction.” The opinion is focused on ovulation induction in women with polycystic ovary syndrome; therefore, we did not include management of other factors such as male factor infertility that may coexist in couples struggling with infertility. Full-Text PDF