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Infertility treatment in PCOS patients Dr S,hosseini Taleghani hospital , IVF centre winter 2015

Infertility treatment in PCOS patients Dr S,hosseini 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

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Infertility treatment in PCOS patients Dr S,hosseini Taleghani hospital , IVF centre winter 2015

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  1. Infertility treatment in PCOS patientsDr S,hosseiniTaleghani hospital , IVF centrewinter 2015

  2. INTRODUCTION • Background • Life style modification • Induction ovulation • Laparoscopic surgery • IVF

  3. PCOS is the single most important cause of infrequent or anovulation • Constituting almost 40% of cases of female infertility

  4. The aim of treatment of infertility in PCOS: • Successful induction of ovulation • without increasing the risks of multiple pregnancy or • ovarian hyperstimulation

  5. Life 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

  6. moderate-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

  7. clomiphene • 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%.

  8. The 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)

  9. Clomiphen resistence : (ovulation failure) • extended use of clomiphene • glucocorticoids • pretreatment with ocp • HCG

  10. Aromatase 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 ?

  11. Letrozole 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

  12. metformin • 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

  13. the 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 ??

  14. the administration of metformin reduces the incidence and severity of OHSS when given to patients with PCOS who undergo multiple ovulation induction for IVF ESHRE guidline 2013

  15. Gonadotrophins • Transient increase in FSH above a threshold dose for sufficient duration Step-up regimens Step-down regimen Sequential step-up and step-down regimen

  16. monoovulatory 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 ?

  17. Laparoscopic 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

  18. Laparoscopic ovarian surgery • Depth 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

  19. There 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

  20. IVF 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

  21. IVF is a reasonable option, because the number of multiple pregnancies can be kept to a minimum by transferring small numbers of embryos.

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