(FOR DOCTORS) Consensus On Fertility Treatment & PCOS

An international panel of specialists has produced a consensus report on fertility treatment related to polycystic ovarian syndrome (PCOS).

The report was drawn up following a 2-day meeting held in March 2007 in Thessaloniki, Greece, at which specialists reviewed and discussed published data with the aim of reaching agreement regarding the management of women with infertility and PCOS.

The meeting was sponsored by the European Society for Human Reproduction and Embryology (ESHRE), the American Society for Reproductive Medicine (ASRM), and pharmaceutical developer Organon.

The consensus report, published in the latest issue of the journal Fertility and Sterility, consists of seven sections covering: lifestyle modification, clomiphene citrate, insulin-sensitizing agents, gonadotropins/GnRH analogues, laparoscopic ovarian surgery, IVF, and ovulation induction/homologous artificial insemination. Each of these sections ends with a number of practical summary points.

The report then ends with a series of overall conclusions. These include the following:

1.Evaluation of women with presumed PCOS desiring pregnancy should exclude any other health issues in the woman or infertility problems in the couple.

2.Preconceptional counseling emphasizing the importance of lifestyle, “especially weight reduction and exercise in overweight women, smoking, and alcohol consumption,” should be provided before any intervention is initiated, the report states.

3.The recommended first-line treatment for ovulation induction remains the anti-estrogen clomiphene citrate (CC).

4.Recommended second-line intervention should CC fail to result in pregnancy is either exogenous gonadotropins or laparoscopic ovarian surgery (LOS). It is pointed out that both have clear advantages and disadvantages, and that the choice must be made on an individual basis.

5.Recommended third-line treatment is IVF because this treatment is effective in women with PCOS. More data on the use of single-embryo transfer in women with PCOS undergoing IVF are awaited, the report states.

The report also identifies a clear need for the development of more patient-tailored approaches for ovulation induction, based on the initial screening characteristics of women with PCOS. It could be that, in certain well-defined subsets of patients, the first-, second-, and third-line treatment recommendations (above) would not apply.

Other conclusions are that the use of metformin in PCOS should be confined to women with glucose intolerance, and that routine use of metformin in ovulation induction is not recommended. In addition, there is currently insufficient evidence to recommend the use of aromatase inhibitors in routine ovulation induction.

The final overall conclusion states: “Even singleton pregnancies in PCOS are associated with increased health risks for both the mother and the fetus.”

Note:

I would also recommend you to read another article by Murizah Mohd Zain et al (Fertility Sterility 2008) from The Adelaide University School of Reproductive Health on the importance of clomiphene as the first line of treatment.

The group assigned 115 newly diagnosed women with PCOS who were naïve to treatment to three groups.

Group 1 received 500 mg of metformin three times a day

Group 2 received CC at an incremental dose

Group 3 received both medications.

The Group reported that ovulation rates with metformin treatment of 23.7 percent, compared with 59.0 percent with CC group, and 68.4 percent with metformin and CC combined. Significant differences were seen between CC and metformin treatment and between combination and metformin treatment, but not between CC and combination treatment.

Ovulation induction led to pregnancy rates that were higher with combined therapy and CC than with metformin, at 21.1 percent and 15.4 percent versus 7.9 percent, respectively.

This led to respective live birth rates of 18.4 percent and 15.4 percent versus 7.9 percent. The group noted that the differences among the three groups in pregnancy and live birth rates did not reach statistical significance.

However the study demonstrated that CC is superior to metformin in inducing ovulation in anovulatory women with PCOS. Adding metformin to CC does not significantly increase the ovulation, pregnancy, and live birth rate.