Today’s post is written by Dr. Rachel Ashby, Director of the Donor Egg and Gestational Carrier Program at the Center for Infertility and Reproductive Surgery at Brigham and Women’s Hospital. This article originally appeared in the Resolve New England newsletter.
Polycystic ovarian syndrome (PCOS) affects between five and ten percent of women. This common endocrine disorder can cause disruption in ovulatory and menstrual cycles, as well as an excess production of male type hormones, all of which can cause infertility. The cause of PCOS is likely a combination of genetic and environmental factors. There is a twenty to forty percent incidence of PCOS in women where either a mother or sister has also been diagnosed with the disorder.
Women with PCOS may present with a range of symptoms, including obesity, acne, hirsutism (male-type hair growth of face), oligomenorrhea (few periods), insulin resistance, and enlarged multicystic ovaries. There is not a specific test to diagnose PCOS. Initially, tests are performed to rule out any other disorders that may mimic the findings of PCOS, such as adrenal disorders or endocrine-active tumors of the ovary. Ultrasound can be a useful diagnostic tool, since the ovaries of patients with PCOS are often enlarged with a multicystic appearance; however, the absence of these findings does not rule out PCOS.
Tests for type 2 diabetes and cardiovascular disease also are performed in obese women suspected of having PCOS. Approximately 50 to 60 percent of women with PCOS are obese, and as many as 30 to 40 percent of these women will develop impaired glucose intolerance or type 2 diabetes. Other metabolic issues that may develop for these women are elevated cholesterol and lipid levels, as well as hypertension.
At the Center for Infertility and Reproductive Surgery, the following treatment options are available to restore regular ovulation and menstrual cycles in women with PCOS and other menstrual irregularities. Individualized treatment plans are developed after a detailed medical history and evaluation take place.
- Weight loss – For obese and overweight women with PCOS, weight loss can restore ovulation and reduce the risk of developing type 2 diabetes and cardiovascular disease.
- Medications - Clomiphene citrate (clomid) is a medication that causes an increase in production of follicle-stimulating hormone (FSH), which promotes development of a mature follicle and ovulation. Approximately 80 percent of women will ovulate with clomid therapy. The risks include a modest increase in a multiple pregnancy (eight percent for twins and less than one percent for a multiple pregnancy higher than twins). Aromatase inhibitors are another class of drugs that may induce ovulation. If patients do not ovulate with clomid, it is unlikely that an aromatase inhibitor will help. Certain forms of FSH can be administered via a subcutaneous injection to induce ovulation. This type of medication must be monitored with blood work and ultrasound to prevent over-response of ovaries, which is a high risk for women with PCOS. There is also a significant increase in the risk of a multiple pregnancy compared to clomid therapy.
- Laparoscopic surgery – Ovarian diathermy is a minimally invasive surgical treatment that can trigger ovulation. This procedure has the benefit of promoting single egg ovulation, thus reducing the risk of multiples. The drawbacks include the short- and long-term risks of surgery.
- In vitro fertilization (IVF) – In vitro fertilization involves mixing egg cells with sperm cells in a laboratory, rather than in the body. Once fertilization occurs, the embryos are transferred into the mother’s uterus, creating a pregnancy that will be carried to term and delivered normally. Several different medications may be given to encourage the production of multiple eggs. Benefits of IVF include an increased pregnancy rate and lower risk of a multiple pregnancy. Drawbacks include increased risk of fetal defects (although this is controversial), as well as the invasive nature of the procedure. Further, young women with PCOS are at increased risk for ovarian hyperstimulation syndrome.
In summary, the diagnosis and management of PCOS can be complex, but many treatment options exist. From an infertility perspective, PCOS is frequently successfully treated and thus has a truly positive prognosis.
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