Zi-Jiang Chen M.D., Ph.D. Center for Reproductive Medicine Shandong ， China Jinan, China

1. The Effect of PCOS Treatment on Ovarian Function Zi-Jiang Chen M.D., Ph.D. Center for Reproductive Medicine Shandong， China Jinan, China

2. 2 1 Ovarian Functions and Influence Factors PCOS infertility treatment 3 PCOS treatment on the ovarian function

3. Ovarian Functions Two main functions Produce oocytes ovulation Synthesize and secrete steroids E2 P T Follicle : basic functional unit. Once recruitment – one follicle maturation more atresia

4. Age No. of oocytesSignificance At birth (1～2)×106 Determination of follicular pool Reproductive time 5×105 Later in the 30s2.5×104Rapid decrease phase( Deteriorationphase) Up to 51 1000Menopause >51 Exhaustion of follicles End of female reproductive life Ovary age

5. 1、 Genetic factors: The size of follicular pool is determined at birth, and different among individuals 2、 Acquired factors: Damage or disease decreases the follicular pool, as it may decrease the ovarian cortex or blood supply Influence Factors on Follicular Pool

6. 2 1 Ovarian Functions and Influence Factors PCOS infertility treatment 3 PCOS treatment on the ovarian function

7. Treatment history of infertility Infertility cause and duration Ovarian function Female age family history Evaluation of pre-treatment Comprehensive Evaluation:

8. PCOS infertility treatment Life style modification Drug Surgery Ovarian function? ART

9. Treatment Strategy For PCOS Treatment Strategy For PCOS-----2 First line treatment Life style: Exercise, smoke and diet Second line treatment Medicine: CC, Letrozole, Gn… new technology: laparoscope, IVF，IVM … Third line treatment

10. Ideal COH protocol Idealized COH protocols: Simple, convenient, economic； High quality oocytes； Better acceptability of the endometrium； Higher implantation rate of single embryo； Avoid or reduce complication.

11. COH with mild stimulation Limitation : more canceled cycles Lower pregnancy rate Simple, low cost Mainly used for poor-responder , low-income patients

12. anovulatary PCOS patient PCOS ovulationinduction Life style modification, body weight, smoking, etc. Clomiphene ovulation stimulation euglycemic agent gonadotropin LOP or … IVF

13. Outcome of CC/LE for PCOS patients in our center Group AgeDuration BMIFSH(IU/L) MC3d LE/HCG 28.07±3.52 3.14±2.42 23.67±3.04 6.33±1.09 CC/HCG 28.73±2.96 3.47±2.75 24.81±3.02 6.96±1.45

14. Ovary function Evaluation Pros and cons of variety Surgical skills are critical PCOS SurgicalTreatment Laparoscopic Ovarian drilling

15. Traditional Wedge resection • Flaws： • POF rate 20-80％ • Pelvic adhesion rate 40-75％ • Lead to irreversible infertility • Flaws： • Pelvic adhesion rate：19%–82% • Ovulation dysfunction due to cicatricleon the surface of ovary • Difficulty in control quality and depth of drilling Laparoscopic ovarian drilling

16. Ultrasound-guided immature follicle aspiration ( IMFA) to treat severe PCOS Schematic diagram for ultrasound mini invasive surgery a Ovary before puncture b Reinspection two weeks after puncture a b

17. Methods PCOS（108 cases） Preoperative use hMG （37 cases） No use hMG （71cases） IMFA 2-3cycles No. of antrum follicles<10/ovary hMG ovulation treatment

18. Ultrasound-guided immature follicle aspiration ( IMFA) to treat severe PCOS

19. Advantages of ultrasound-guided immature follicle aspiration for PCOS infertility treatment： Smaller lesion，safe , less pelvic adhesion reduce OHSS risk by decreasing number of antral follicles directly, No risk of POF Improve metabolic and endocrine status of PCOS patients Shortage: temporarily, invasively

20. 2 1 Ovarian Functions and Influence Factors PCOS infertility treatment 3 PCOS treatment on the ovarian function

21. The safety issue of Clinical treatment forPCOS The safety during ovulation induction PCOS patients The safety in ART The safety of minimally invasive surgery (LOD, Transvaginal Ultrasound puncturation)

22. ovarian hyperstimulation syndrome multiple pregnancy ovulation induction and tumor ovulation induction and ovarian functional lesion Safety issues in ovulationinduction

23. Ovulation induction and ovarian cancer 3837 cases infertility patients for 7-18 years, shows that using CC for over 12 months, the onset risk of ovarian cancer and ovarianborderline tumorincreased. In patients with ovulation induction: ovarian cancer elevated 2.8 folds, ovarianborderline tumor increased 4 folds Rossing MA et al N Engl J Med. 1994 Sep 22;331(12):771-6 Whittemore AS et al Am J Epidemiol. 1992 Nov 15;136(10 .

24. Reports on ovarian tumor after ovulation induction 33 cases with epithelial cancer 16 cases with borderline tumour 15 cases with granular cell tumor 1 case with malignant teratoma Average onset age is 30.3-year-old,which is 20 years earlier than normal onset age Ali Mahdavi, et al. Farr Nezhat. 2006,85(4):819-826 Franco C,et al. 2000 Apr;52(4):103-9.

25. Can repeated stimulated ovulation influence ovarian reserve by excessive consumption of follicles?Can it influence normal menstrual cycle and even if cause premature menopause？For PCOS patients，superovulation can only decrease Antral Follicle Numbers and ameliorate menstrual cycle for a short time, no influence on ovarian reserve function Ovulation stimulation and ovarian reserve Nikolaou D et al. Hum Reprod. 2002 Apr;17(4):1106-11. de Boer EJ et al. Fertil Steril. 2002 May;77(5):978-85

26. Repeated superovulation is non-physiological stimuli, over consumption of follicle may exceed physiological limit So far, no strong evidence show a adverse influence on ovarian reserve Mild stimulation schemes has been advocated large sample studies are needed in the future Ovulation stimulation and ovarian reserve

27. Take home messages Welcome to Expo China Treat PCOS patients with Minimum cost Maximum efficiency Never forget to treasure ovaries!