Back to Search Results

8/1/2017

Infertility in patients with PCOS

Author: Loriana Soma, MD

Registered users can also download a PDF or listen to a podcast of this Pearl.
Log in now, or create a free account to access bonus Pearls features.

Editors: Julie Decesare, MD and Eduardo Lara-Torre, MD

Polycystic ovarian syndrome (PCOS) is the leading cause of infertility in reproductive age women. Anovulation is generally assumed to be the cause after other anatomic, hormonal, and male factor causes are ruled out. A semen analysis should be performed to rule out male factor, and a HSG should be considered in high risk patients (previous PID, ectopic history, endometriosis) prior to initiating ovulation induction.

Ovulatory function may be assessed by a mid-luteal phase serum progesterone level or urinary ovulation predictor kits. Patients with obvious patterns of anovulatory bleeding may not need further testing to confirm ovulatory dysfunction.

Prior to ovulation induction, preconception counseling should include recommended lifestyle changes such as weight reduction, increased exercise, and smoking cessation.  As insulin resistance and obesity may contribute to infertility, subsequent weight loss of as little as 7% of body weight can improve ovulatory function and pregnancy rates.

Risks of ovulation induction include ovarian hyperstimulation syndrome and multiple pregnancies, which may be increased in women with PCOS. These medications should be started during the early follicular phase and continued for 5 days. Dosing may be increased if ovulation does not occur.

Letrozole, an aromatase inhibitor, is the first line treatment for women with PCOS. It has an increased live birth rate when compared to clomiphene citrate (27% vs 19%) and has lower ovarian hyperstimulation and multiple pregnancy rates. Metformin is an insulin-sensitizing agent that is used in some women with PCOS who have impaired glucose tolerance or difficulty with weight loss.  In women already using metformin who also need ovulation induction, clomiphene citrate may be added to improve pregnancy rates. Its use as a single agent for ovulation induction is not indicated.

If ovulation induction does not occur after 3 to 6 cycles with letrozole or clomiphene citrate, second line treatments with gonadotropins may be initiated. Risks of injectable gonadotropins include multiple pregnancies and ovarian hyperstimulation syndrome. Up to 30% of gonadotropin-stimulated pregnancies are multiples, one third of them triplets or higher order.

Laparoscopic ovarian surgery including ovarian drilling or laser diathermy has unclear benefit on ovarian function.  It can be used as a second line treatment and may provide temporary increase in fertility. It has not shown to be superior to gonadotropins in pregnancy rates, but may have a decreased risk of multiple births. The long term effects of these techniques are unknown.

 

Further reading:

American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 194: Polycystic Ovary Syndrome. Obstet Gynecol. 2018 Jun;131(6):e157-e171. doi: 10.1097/AOG.0000000000002656.

American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 738: Aromatase Inhibitors in Gynecologic Practice. Obstet Gynecol. 2018 Jun;131(6):e194-e199. doi: 10.1097/AOG.0000000000002640.

Initial approval July 2017. Revised January 2019

 

********** Notice Regarding Use ************

The Foundation for Exxcellence in Women’s Health, Inc (“Foundation”) is committed to accuracy and will review and validate all Pearls on an ongoing basis to reflect current practice.

This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The Foundation reviews the articles regularly; however, its publications may not reflect the most recent evidence. While we make every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. The Foundation does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither the Foundation, the ABOG, SASGOG nor their respective officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

Copyright 2019 The Foundation for Exxcellence in Women's Health, Inc. All rights reserved.  No re-print, duplication or posting allowed without prior written consent.

 

Back to Search Results