PCOS
Treatment Guidelines
&
Review of
Newer Medical Treatment in Infertility
Dr. Sharda Jain
Dr. Jyoti Agarwal
Dr. Jyoti B...
ESHRE/ ASRM sponsored PCOS
Consensus Workshop
• 1st workshop (2004) on Diagnosis
• 2nd workshop (2008) on Infertility
• 3r...
PCOS Phenotypes as per Rotterdam criteria
PCOS Phenotype Oligo – or
an ovulation
Biochemical
hyperandrogene
mia or clinica...
MENSTRUAL DISORDERS: PCOS mostly produces oligomenorrhea
or amenorrhea.
INCREASED LH/FSH RATIO - Prevents follicular mat...
Look for C0- morbidities in PCOS
coming for infertility Treatment
•HERSUITISM & ACNE
•CENTRAL OBESITY
•TYPE-2 DIABETES
•HI...
Management of Infertility in PCOS
WHO Group – II Ovulation Disorder
Classic
PCOS
Anovulatory
PCOS
Ovulatory
PCOS
NICE/ ASR...
Women with WHO group II anovulatory
infertility with PCOS who have a BMI of 30
or over must lose weight. Inform them that
...
Life style management
of Weight Reduction
• 50% treatment of PCOS is simply – weight
control.
• Even if one loses 5-10 kg ...
One of the following treatments taking into
account potential adverse effects, ease and
mode of use, the women’s BMI
• Clo...
Clomifene Citrate
• For women who are taking clomifene
citrate, do not continue treatment for longer than 6
months
•Women ...
Experience of Infertility Experts on
Role of Metformin in PCOS
• CC compared with metformin aloneresults
in higher ovulati...
PCOS Patients with
Anovulation & Ovulation disorder
RESISTANT TO CLOMIFENE CITRATE:
For women with PCOS who are known to b...
CLOMIFENE CITRATE + Metformin
However, Recent Study showed
CC+ metformin combination therapy
results in hyper rates of LIV...
Caution
Women with PCOD who are being treated
with gonadotrophins should not be offered
treatment with gonadotrophin – rel...
The use of Adjuvant Growth Hormone
treatment with gonadotrophins – releasing
hormone agonist and / or human
menopausal gon...
INTRODUCING
Concepts & Rationale
of
A NEW LINE OF TREATMENT
↓
Still not approved by
NICE GUIDELINES
& ASRM
PATHOGENESIS of PCOS
INSULIN RESISTANCE
HYPERINSULINEMIA
THECA CELL
PROLIFERATION
HYPERANDROGENISM
PCOS
Infact, No Body Kn...
Oxidative Stress & Infertility
Basis of Newer Drugs use
Summary of
Review of literature shows
MELATONIN
•Recent entry
•Melatonin is also known as N-acetyl-5 methoxytryptamine
•An hormone secreted during the dark hour...
However, the discovery of melatonin as a
direct free radical scavenger has greatly
broadened the understanding of
melatoni...
•It has been discovered that melatonin is a powerful
free radical scavenger and a broad-spectrum antioxidant.
Because of i...
Melatonin, secreted by pineal gland, is taken up into
the follicular fluid from the blood.
ROS produced within the folli...
Comes from the amino acid l-cysteine. Amino acids
are the building blocks of protein
Improves insulin sensitivity & decr...
•Decreases circulating insulin & serum total
testosterone
•Reduces acne & weight
•Reduces hirsutism and hyperandrogenism a...
Is an analogue of vitamin D used for supplementation
in humans .
More useful form of vitamin D supplementation,
mostly due...
Chromium polynicotinate consists of pure niacin-bound
chromium
Chromium polynicotinateis more effective than other
types o...
•Active component of glucose tolerance factor which
is responsible for binding insulin to cell membrane
receptor sites
•Im...
Is the natural, active form of folic acid used at the
cellular level for DNA reproduction and the regulation
of homocystei...
Recap
• 50% treatment of PCOS is simply – weight
control.
• Even if one loses 5-10 kg - the effect is
tremendous .
Experie...
Please Remembers
There is NO approval of these drugs in NICE &
ASRM Guidelines
& Drugs controlled of India for Ovulation I...
Summary
Infertility in PCOS
• Exclude other diseases & other fertility
disorders in the couple.
• Life style modification ...
ADDRESS
35 , Defence Enclave, Opp. Preet
Vihar Petrol Pump, Metro pillar
no. 88, Vikas Marg , Delhi –
110092
CONTACT US
01...
PCOS Treatment Guidelines  &  Review of  Newer Medical Treatment in Infertility Dr. Sharda Jain
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PCOS Treatment Guidelines & Review of Newer Medical Treatment in Infertility Dr. Sharda Jain

  1. 1. PCOS Treatment Guidelines & Review of Newer Medical Treatment in Infertility Dr. Sharda Jain Dr. Jyoti Agarwal Dr. Jyoti Bhaskar
  2. 2. ESHRE/ ASRM sponsored PCOS Consensus Workshop • 1st workshop (2004) on Diagnosis • 2nd workshop (2008) on Infertility • 3rd workshop (2011) Women’s Health Aspects of PCOS Must Reading for all of you
  3. 3. PCOS Phenotypes as per Rotterdam criteria PCOS Phenotype Oligo – or an ovulation Biochemical hyperandrogene mia or clinical manifestation of hyperandrogene mia Polycystic ovaries in transvaginal ultrasound 1- Severe PCOS + + + 2- Oligo – or anovulation and hyperandrogene mia + + - 3- ovulatory PCOS - + + 4- MILD pcos + - +
  4. 4. MENSTRUAL DISORDERS: PCOS mostly produces oligomenorrhea or amenorrhea. INCREASED LH/FSH RATIO - Prevents follicular maturation resulting in anovulation HIGH LEVELS OF ANDROGEN HORMONE: The most common signs are acne, acanthosis nigricans, androgenic alopecia & hirsutism. METABOLIC SYNDROME: This appears as a tendency towards central obesity and other symptoms associated with insulin resistance. Common Symptoms of PCOS Other than INFERTILITY Serum insulin, insulin resistance and homocysteine levels are higher in women with PCO.
  5. 5. Look for C0- morbidities in PCOS coming for infertility Treatment •HERSUITISM & ACNE •CENTRAL OBESITY •TYPE-2 DIABETES •HIGH BLOOD PRESSURE •CHOLESTEROL ABNORMALITIES •HYPOTHYROIDISM •HYPERPROLACTINEMIA
  6. 6. Management of Infertility in PCOS WHO Group – II Ovulation Disorder Classic PCOS Anovulatory PCOS Ovulatory PCOS NICE/ ASRM Guidelines
  7. 7. Women with WHO group II anovulatory infertility with PCOS who have a BMI of 30 or over must lose weight. Inform them that this alone may restore ovulation, improve their response to ovulation induction agents, and have a positive impact on pregnancy outcomes Life style management of Weight Reduction (NICE 2013)
  8. 8. Life style management of Weight Reduction • 50% treatment of PCOS is simply – weight control. • Even if one loses 5-10 kg - the effect is tremendous . Experience
  9. 9. One of the following treatments taking into account potential adverse effects, ease and mode of use, the women’s BMI • Clomifene Citrate or • Metformin or • A combination of the above ESRE / ASRM consensus workshop on PCOS Anovulatory Infertility Cycle clinical follicle monitoring needed: (NICE 2013)
  10. 10. Clomifene Citrate • For women who are taking clomifene citrate, do not continue treatment for longer than 6 months •Women prescribed metformin should be informed of the side effects associated with its use (such as nausea, vomiting and other gastrointestinal disturbances) (NICE 2004) (NICE 2013)
  11. 11. Experience of Infertility Experts on Role of Metformin in PCOS • CC compared with metformin aloneresults in higher ovulation , conception, pregnancy & live birth rate • CC + Metformin results in no substantial benefits except, patients with BMI >35 or abnormal GTT Fertile sterile 2008,89;505
  12. 12. PCOS Patients with Anovulation & Ovulation disorder RESISTANT TO CLOMIFENE CITRATE: For women with PCOS who are known to be resistant to clomifene citrate, consider one of the following SECOND – LINE TREATMENT, depending on clinical circumstances and the women’s preference • Laparoscopic Ovarian drilling or • Combined treatment with clomifene citrate and metformin if not already offered as fist – line treatment or • Gonadotrophines (NICE 2013)
  13. 13. CLOMIFENE CITRATE + Metformin However, Recent Study showed CC+ metformin combination therapy results in hyper rates of LIVE BIRTHS compared with other treatments. Jungheim et. all fertil steril 2010;94:2659
  14. 14. Caution Women with PCOD who are being treated with gonadotrophins should not be offered treatment with gonadotrophin – releasing hormone agonist concomitantly because it does not improve pregnancy rates and it is associated with an increase risk of ovarian hyperstimulation (NICE 2004)
  15. 15. The use of Adjuvant Growth Hormone treatment with gonadotrophins – releasing hormone agonist and / or human menopausal gonadotrophin during ovulation induction in women with PCOS who do not respond to clomifene citrate is not recommended because it does not improve pregancy rates Caution (NICE 2004)
  16. 16. INTRODUCING Concepts & Rationale of A NEW LINE OF TREATMENT ↓ Still not approved by NICE GUIDELINES & ASRM
  17. 17. PATHOGENESIS of PCOS INSULIN RESISTANCE HYPERINSULINEMIA THECA CELL PROLIFERATION HYPERANDROGENISM PCOS Infact, No Body Knows exact Cause !!
  18. 18. Oxidative Stress & Infertility
  19. 19. Basis of Newer Drugs use
  20. 20. Summary of Review of literature shows
  21. 21. MELATONIN •Recent entry •Melatonin is also known as N-acetyl-5 methoxytryptamine •An hormone secreted during the dark hours by pineal gland. •Regulates a variety of important central and peripheral •actions related to circadian rhythms and reproduction.
  22. 22. However, the discovery of melatonin as a direct free radical scavenger has greatly broadened the understanding of melatonin’s mechanisms which benefit reproductive physiology. MELATONIN
  23. 23. •It has been discovered that melatonin is a powerful free radical scavenger and a broad-spectrum antioxidant. Because of its small size and highly lipophilic & hydrophilic properties, melatonin crosses all cell membranes & easily reaches subcellular compartments,including mitochondria and nuclei, where it seems to accumulate in high concentrations. •Melatonin prevents lipid peroxidation, protein, and DNA damage. MELATONIN
  24. 24. Melatonin, secreted by pineal gland, is taken up into the follicular fluid from the blood. ROS produced within the follicles, especially during the ovulation process, were scavenged by melatonin, and reduced oxidative stress involved in oocyte maturation and embryo development Melatonin increases intra-follicular melatonin concentrations, reduces intra-follicular oxidative damage Elevates fertilization and pregnancy rates. MELATONIN
  25. 25. Comes from the amino acid l-cysteine. Amino acids are the building blocks of protein Improves insulin sensitivity & decreases androgen level Prevents follicular cohort atresia Improves quality of cervical mucus N-ACETYLCYSTEINE
  26. 26. •Decreases circulating insulin & serum total testosterone •Reduces acne & weight •Reduces hirsutism and hyperandrogenism and ameliorates the abnormal metabolic profile of women with hirsutism After 3 months of inositol administration, free testosterone, insulin and HOMA index resulted in significantly reduced. Both hirsutism and acne decreased after 6 months of therapy. MYO-INOSITOL
  27. 27. Is an analogue of vitamin D used for supplementation in humans . More useful form of vitamin D supplementation, mostly due to much longer half-life and lower kidney load Improves insulin secretion. ALFACALCIDOL
  28. 28. Chromium polynicotinate consists of pure niacin-bound chromium Chromium polynicotinateis more effective than other types of chromium, because it binds to niacin also know as vitamin b-3. This provides a biologically active form of chromium, and makes it easier for the body to absorb CHROMIUM POLYNICOTINATE
  29. 29. •Active component of glucose tolerance factor which is responsible for binding insulin to cell membrane receptor sites •Improves insulin sensitivity •Stimulates the metabolism of sugar, fat & cholesterol CHROMIUM POLYNICOTINATE:
  30. 30. Is the natural, active form of folic acid used at the cellular level for DNA reproduction and the regulation of homocysteine among other functions. Reduces homocysteine levels and prevent cardiovascular risk factors associated with PCOS. The un-methylated form, folic acid (vitamin B9), is a synthetic form of folate found in nutritional supplements. L-METHYLFOLATE
  31. 31. Recap • 50% treatment of PCOS is simply – weight control. • Even if one loses 5-10 kg - the effect is tremendous . Experience
  32. 32. Please Remembers There is NO approval of these drugs in NICE & ASRM Guidelines & Drugs controlled of India for Ovulation Induction Few Drug House have stared marketing NAC & combination of NAC with these drugs to be given with CC Please Note
  33. 33. Summary Infertility in PCOS • Exclude other diseases & other fertility disorders in the couple. • Life style modification particularly weight loss increase exercise, smoking cessation & decrease alcohol consumption is highly recommended. • The Pharmacological treatment approved by NICE/ ASRM is CC or CC+ metformin. •Second line treatment i.e. gonadotrophines or laparoscopic ovarian drill if medical treatment fails. •NICE & ASRM do not endorse use of newer drugs (2013)
  34. 34. ADDRESS 35 , Defence Enclave, Opp. Preet Vihar Petrol Pump, Metro pillar no. 88, Vikas Marg , Delhi – 110092 CONTACT US 011-22414049, 42401339 WEBSITE : www.lifecarecentre.in www.drshardajain.com www.lifecareivf.com E-MAIL ID Sharda.lifecare@gmail.com Lifecarecentre21@gmail.com info@lifecareivf.com

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