Tuesday, October 5, 2010

My chances with Polycystic Ovarian Syndrome ?

Today was endocrine clinic day...and I saw a 22 yo black female with secondary amenorrhea of 3 years duration.sought medical attention 3 weeks ago.....found to have diabetes....started on Metformin...and referred to us. She was obese & had some facial hair. Her labs are Hb- 12.8, MCV- 76, LFT- normal, Na,K, BUN, Creatinine - normal. Her TSH- Normal, LH- 6.1 mIU/ml, FSH -4.6mIU/ml, testosterone lvl- 49ng.dl (high normal is 40), DHEAS, androstenidione, 17OH progesterone - Normal. US - no ovarian cysts. She had a progesterone challenge...following which she had bleeding. She has anovulatory PCOS.
Her main concern was about her chances of getting pregnant?

Lets first look at the criteria for diagnosing PCOS. The latest criteria is from 2003..called Rotterdam Criteria ...and calls for presence of 2 of following 3 ...... a)Oligo‐ and/or anovulation b)Clinical and/or biochemical signs of hyperandrogenism c) Polycystic ovaries ...and exclusion of other causes. Our pt had 2 of the above(a & b).

There has been a good amount of evidence linking ovarian problems in PCOS to hyperinsulinemia and Insulin resistance. Insulin affects stromal proliferation etc.Have a look at this review. This forms the basis of treating these pts with Metformin......also there is more regularisation of menstrual cycle with Metformin(NEJM 2008). Other main treatment options for anovulation are Clomiphene(frequently used as first line) and lastly GnRH or lap surgery for cysts. A combination of these drugs (meformin & clomiphene) does not offer an added benefit for inducing ovulation ( Clin Endocrine 2009 & Cochrane 2009)

What are the chances of this lady getting pregnant? Well...few facts..... 
6- 10 % of fertile women satisfy criteria for PCOS. 
PCOS is the underlying cause in 70% of pts with anovulatory infertility.
In patients with anovulatory PCOS..the infertility rate is high and varies widely. Its difficult to find the exact prevalance of infertility among patients with PCOS. But ..look at this long term study (10-20 years)showing a spontaneous fertility rate of 87% in PCOS(mostly with oligomenorrhea) compared to 91% in normal controls. Also.. treatment with Clomiphene has shown pregnancy rates of 70%   just after 4 ovulatory cycles (Hum Reproduction). 
So our patient has a very good chance of getting pregnant with treatment. For now she is going to be on Metformin ( she needs to be..due to diabetes) hoping it might help with ovulation as well. If not..she will be started on Clomiphene for ovulation induction. Then we have IVF which also has good success rates.


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