Ovulation Induction Protocols for PCOS Patients Practical Aspects

Polycystic ovarian syndrome (PCOS) is a group of heterogeneous endocrine diseases affecting women characterized by irregular menses, hyperandrogenism, and polycystic ovaries. The diagnoses of Polycystic ovarian syndrome are frequently made for the first time in the infertility clinic during evaluations for infertility. Infertility is the primary clinical manifestation of ovulatory dysfunction in patients with PCOS.

Central to the management of women with infertility from PCOS is ovulation. The treatment options for infertility in women with PCOS include clomiphene citrate, gonadotropins, laparoscopic ovarian drilling (LOD), and assisted reproductive technology. Common to all methods is the induction of ovulation. Letrozole and metformin also play essential roles in ovulation induction, which has been well demonstrated. The use of these pharmacologic agents is superior to placebo or no treatment in terms of pregnancy or ovulation.

Several pharmacologic agents have been used to induce ovulation in these patients. They have achieved varied success with attendant setbacks from these drugs, especially in achieving pregnancy and adverse pregnancy outcomes. These drugs include clomiphene citrate, metformin, letrozole, gonadotropins, inositol, and tamoxifen.

Laparoscopic ovarian drilling has been demonstrated to induce ovulation in women with PCOS. This method of ovulation induction is used for clomiphene-resistant and FSH-resistant PCOS. The mechanism involved in the ovarian diathermy is that it leads to the correction of hypersecretion of LH brought about by modification of the ovarian pituitary feedback. The practice is to drill into both ovaries.

Bariatric surgery has been used for weight reduction among highly obese women who had bariatric surgery for just weight reduction. The bariatric surgery in obese PCOS patients also resulted in weight loss, spontaneous ovulation, and pregnancy.

Women with PCOS should undergo pre-conception counselling before any infertility treatment. The importance of lifestyle modification, especially weight loss and exercise, should be emphasized and encouraged in overweight women, and smoking and alcohol consumption should be discouraged. More randomized trials to determine the effect of weight loss on ovulation should be undertaken to elucidate the place of weight loss as a means of ovulation induction, considering its affordability and acceptability as a means of treatment.

The controversy with treating anovulatory infertility in women with PCOS will continue for some time. The systemic review found that the clomiphene citrate combined with metformin was the most productive, followed by follicle-stimulating hormone, letrozole, metformin, clomiphene and tamoxifen, laparoscopic ovarian drilling, and placebo or no treatment in that order. However, when the ranking in terms of live birth rate was done, letrozole, follicle-stimulating hormone, clomiphene-metformin, tamoxifen, clomiphene citrate, metformin, placebo, or no treatment was noted. Therefore, it will seem reasonable to include letrozole, clomiphene citrate, and the combination of clomiphene citrate with metformin as possible first-line drugs in the treatment of anovulatory infertility in women with PCOS. While gonadotropins are reserved as a second-line drug for these women, ovarian drilling is recommended after failure with the gonadotropins or whenever laparoscopy is indicated for any other reason in these women with failed clomiphene resistance. It will be advisable to refer patients who fail to achieve pregnancy using the methods above for assisted reproductive therapy to treat their anovulatory infertility.