Disorders of ovulation are common causes of infertility and polycystic ovarian syndrome (PCOS) is the most frequent condition. In general population, PCOS has a prevalence of 5%-15% depending upon the phenotype and ethnicity. Women of all races and ethnicities are at risk of PCOS. It is one of the most common causes of ovulatory infertility with a prevalence of 4 -7% Most commonly used criteria for diagnosis is the Rotterdam criteria which includes menstural disturbance (oligo or an ovulation), clinical or biochemical signs of hyperandrogenism (acne, hirsutism, male pattern baldness and hoarseness of voice) and polycystic ovarian morphology on ultrasound examination. Obesity is present in over 50% of PCOS women. Hyperandrogenism is characterized by higher than normal levels of androgens which interfere with folliculogenesis and ovulation. Women with PCOS often have an increased pulsatility of gonadotropin-releasing hormone (GnRH) resulting in increased pituitary release of Luteinizing Hormone (LH) and an elevated LH/FSH ratio. Increased LH stimulates excess androgen synthesis. Intraovarian androgens within normal levels stimulate the growth of prenatal and early antral follicle stages but at a higher levels induce atresia in later antral stage of follicular growth. PCOS is also characterized by increased Anti-Mullerian Hormone levels which makes the Pre antral follicles unresponsive to FSH thus hampering follicular growth and ovulation. Hypersecretion of LH also leads to hyperinsulinemia and insulin resistance characterized by darkening of skin particularly along neck creases,in the groin and underneath breasts. Hence PCOS patients are at increased risk of diabetes in the long-term.
Treatments of anovulatory related infertility aim to shift the balance of intraovarian steroid synthesis away from an LH driven excessive androgen synthesis towards a FSH driven steroid synthesis that helps in final development of a dominant follicle.
Several treatment options are available to treat infertility in PCOS women. As PCOS is often associated with obesity the first step in treatment of such women is lifestyle modification which includes a healthy diet and exercise. A diet that is low in carbohydrates and high in protein content reduces the glycemic load which helps in weight loss and corrects hormonal imbalance. Recommended exercise in PCOS women is at least 30 minutes of moderate exercise daily. Weight reduction reduces hyperinsulinemia and insulin resistance, and increased physical activity increases insulin sensitivity. This improves the hormonal balance in the ovary and reduces androgen dominance. A steady decrease in weight seems to be more important than the actual amount of weight lost. Even 5% decrease in patients body weight has shown to improve fertility.
Women who still have infrequent ovulation despite lifestyle modifications may require fertility medications called as ovulation inducing drugs like Clomiphene Citrate and Letrazole to assist with follicular growth and ovulation. Some PCOS patients do not respond to these ovulation inducing drugs may require Gonadotropin injections. In ovarian resistant PCOS women no response is achieved with either oral tablets or injections and such patients can benefit from either laparoscopic ovarian drilling or IVF to achieve pregnancy. Laparoscopic ovarian drilling (LOD) in CC-resistant PCOS women is beneficial in highly selected cases, particularly in those with hyper secretion of LH, shorter duration of infertility and normal BMI. The mechanism by which LOD benefits resistant PCOS is by reducing the levels of Testosterone, Androstenedione,Estradiol and LH. IVF in PCOS patients has proven to have good success rates.