1. Pco .
DR G A RAMA RAJU.
Krishnaivf

2. PCOS .WOMB TO TOMB

3. Lecture outline
Diagnostic work up.
Implication for health.
Implication for infertility.
Implication for pregnancy.

4. Diagnostic pcos criteria
hyeperandrogen
ism
Oligo/ameno
POS
rrhea
NIH Rott Cons AES

5. • To diagnose pcos the following are needed
• ACOG practice bulletin ,OG,oct 2009
• Physical exam.
• Laboratory
• Ultrasound
• Optional test

6. Physical.
• Blood pressure.
• BMI.
• Waist circumference.
• Presence of stigmata
hyperandrogenism.
ACOG practice bulletin ,OG,oct 2009

7. • TSH.
laboratory
• Prl.
• 17-0hprog
• Consider screening for Cushing and
acromegaly
• Evaluation metabolic abnormalities.
• Fasting Lipid and lipoprotein levels
ACOG practice bulletin ,OG,oct 2009

8. • Ultrasound
ACOG practice bulletin ,OG,oct 2009

9. Optional tests
• Gonadotrophins
• Fasting Ins in young women
• 14h urinary free cortisol
ACOG practice bulletin ,OG,oct 2009

11. Morphology Syndrome Endocrinology Ultrasound Metabolic
1935 1963 1980 1988 1990
45% metabolic 70 % 60% insulin
syndrome 0besity resistance

12. What is Metabolic syndrome
Blood pressure
>130/85
Abdominal obesity
triglycerides >150
Hdl cholesterol < 50
mg/dl
Faasting glucose >110
mg /dl

13. Metabolic syndrome marker for cardiovascualr disease
Blood
Dyslipedemia
pressure
Insulin Central
resistance obesity

14. a condition requiring life long attention.
Reproductive disorder
Metabolic disorder
15 yrs………………………
60 yrs

15. Implication for future health

16. Pcos follow up studies
• More diabetes , hypertension and
• cerebro vascular disease
24

17. INCREASED INCIDENCE OF OBESITY

18. Cardio vascular risk.
• Gender
• Age
• Systolic pressure
• Smoking
• Cholesterol

19. • ROLE AND RESPONSIBILITY OF THE
DOCTOR IN PCO
– HEALTH PRECAUTION
– HEALTH EDUCATION
– TREATMENT

20. IMPLICATION FOR INFERTILITY

21. • Optimal treatment of PCOS has not
been identified

23. Life style modification

24. 500 kcal/day deficit with reduced
glycemic load
DIET

25. Life style modification
• Attention to weight and metabolic syndrome.
• Should happen before treatment

26. First line of drug
• Clomiphene citrate
Ovulation rate 73 % and pregnancy rate 37 %

27. 50 yrs ago

28. Starting dose 50 – to 150 mg
Ovulation Ovulation /Nopregnancy
and No
(laproscopy/letrizole/gonado
Pregnancy(6
trophin male factor)
response
cycle)

29. Age
issues
Dose
Clomiphene citrate
Monitoring
75% OVULATION RATE
DURATION
COMBINATION NO ADDITIOAL
BENEFITS
Obesity

30. Source: Fertility and Sterility 2008; 89:505-522 (DOI:10.1016/j.fertnstert.2007.09.041 )
Copyright © 2008 American Society for Reproductive Medicine Terms and Conditions

31. Second line of treatment
• Gonadotropin
• Laparoscopy ovarian drilling

32. AN operation which became obsolete

33. Laparoscopic ovarian drilling

34. Laparoscopy ovarian drilling
• Cc resistance
• Women needing laparoscopy .
• (best for normal bmi ,shorter duration of infertility)

35. GONADOTROPHIN
VS DRILLING

36. Where does metformin fit
• Glucose intolerance.
• Role in obese > 35 .
• CC resistance.
In 2006 2 large RCT did not show any benifit

37. Gonadotropin therapy
Step up Step down
Avoid multiple follicle and hyperstimulation

38. Gonadotropin therapy
1. THE RECOMMENDED STARTING DOSE OF GONADOTROPIN
IS 37.5–50.0 IU/DAY.
2 SMALL FSH DOSE INCREMENTS OF 50% OF THE INITIAL OR
PREVIOUS
3 PREVENTING ALL MULTIPLE PREGNANCIES AND OHSS IS
NOT
POSSIBLE AT THIS TIME.

39. DURATION OF GONADOTROPIN THERAPY
INTENSE OVARIAN RESPONSE MONITORING
STRICT CYCLE CANCELLATION CRITERIA.

40. CC FAILURE
LETRIZOLE
CC RESISTANCE
NOT A FIRST LINE OF
TREATMENT

41. Third line of management
• Assisted reproduction: IVF

42. Implication for pregnancy

43. GESTATIONAL DIABETES
20 T0 24 WEEKS GLUCOSE SCREEN

44. PREGNANCY INDUCED HYPERTENSION
BP / URINE ALBUMIN

45. PRETERM AND PCOS
ASSESMENT OF CERVIX AND PRECUATIONS

46. Birth weight

47. NICU ADMISSION

48. PERINATAL MORBIDTY
Higher nicu admission

49. Boomsma, C.M. et al. Hum Reprod Update 2006 12:673-683; doi:10.1093/humupd/dml036
Copyright restrictions may apply.

50. Prevalence of metabolic syndrome at
the age of 65 yrs in relation to birth
weight

51. Diagnostic Algorithm for the Polycystic Ovary Syndrome
Ehrmann D. N Engl J Med 2005;352:1223-1236

53. Dr G A RAMA RAJU
• Krishna ivf clinic Visakhapatnam.
• Visiting professor Giessen university
Germany.
• Published 8 article in peer review journal
with 70 citations
• PhD guide in human genetics ,andhra
university.

54. THANK YOU