The treatment of infertile women with polycystic ovary syndrome (PCOS) is surrounded by many controversies. This paper describes, on the basis of the currently available evidence, the consensus reached by a group of experts regarding the therapeutic challenges raised in these women.
Before any intervention is initiated, preconceptional counselling should be provided emphasizing the importance of life style, especially weight reduction and exercise in overweight women, smoking and alcohol consumption.
The recommended first-line treatment for ovulation induction remains the anti-estrogen clomiphene citrate (CC).
Recommended second-line intervention, should CC fail to result in pregnancy, is either exogenous gonadotrophins or laparoscopic ovarian surgery (LOS). The use of exogenous gonadotrophins is associated with increased chances for multiple pregnancy and, therefore, intense monitoring of ovarian response is required. LOS alone is usually effective in <50% of women and additional ovulation induction medication is required under those circumstances. Overall, ovulation induction (representing the CC, gonadotrophin paradigm) is reported to be highly effective with a cumulative singleton live birth rate of 72%.
Recommended third-line treatment is in vitro fertilization.
More patient-tailored approaches should be developed for ovulation induction based on initial screening characteristics of women with PCOS. Such approaches may result in deviation from the above mentioned first-, second- or third-line ovulation strategies in well-defined subsets of patients.
Metformin use in PCOS should be restricted to women with glucose intolerance.
Based on recent data available in the literature, the routine use of this drug in ovulation induction is not recommended.
Insufficient evidence is currently available to recommend the clinical use of aromatase inhibitors for routine ovulation induction.
Even singleton pregnancies in PCOS are associated with increased health risk for both the mother and the fetus.
This makes me curious about my own DX. I am on 2000 mg of Metformin since May.
I had a normal fasting glucose when they checked a few months ago. BUT, 12 years ago, during my one and only pregnancy, I was insulin dependant. I guess the endo thought this was enough evidence of my IR?
It is amazing to me now that I conceived at all. I had just stopped taking BCP and was pregnant the next month. I never had a regular period without BCP. I bet I had just that little window of opportunity.....
Who knows!!!?
Great article! I'm really liking the sidebar stuff!
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This makes me curious about my own DX. I am on 2000 mg of Metformin since May.
I had a normal fasting glucose when they checked a few months ago. BUT, 12 years ago, during my one and only pregnancy, I was insulin dependant. I guess the endo thought this was enough evidence of my IR?
Did you ever have IR symptoms before using Met?
And I love the sidebars too! I've read every article...
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See this is what is strange to me... my fasting glucose was fine but I definitely have the tell tale belly of IR and an inability to lose weight ( even with extreme exercise and dieting ).... the doc's ordering more tests for me.
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Current weight : 186 ** and hopefully still dropping **
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See this is what is strange to me... my fasting glucose was fine but I definitely have the tell tale belly of IR and an inability to lose weight ( even with extreme exercise and dieting ).... the doc's ordering more tests for me.
Complete inability to lose weight 'even with extreme exercise and diet' isn't not a feature of IR.
In fact, exercise typically improves IR.
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Hey, SoulCysters! Need to eat more veggies, but can't find recipes??
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I am personally not so sure about this article, suggesting not using Metformin for not IR women. Everything else I have ever read before, suggests Met to show improvements in non IR women like myself. I am totally anovulatory without Met, likewise I wouldn't have conceived my DD if I wasn't on Met. I am right now TTC #2, and I have about 40 day cycles with Met. Met has normalized my hormone levels too.
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Ali (31) DH (33) married 4-04
Current Meds: Met XR, Prenatal, Omega-3
7-05 bfp Met XR 2,000mg 1-09 bfp 2nd round clomid 50mg + Met XR 2000mg
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I brought my doc a very large study published that my sis in law gave me (Ph.D at FSU) and he did acknowledge that people debate using met but many in the states feel that it does help and is worth the try.
__________________ Adrienne
Me(22) DH(28)
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DX: 5/08
DH S/A: Perfect!
RX: Prenatal
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1 Reg. cycle so far!!
Looks like this cycle maybe a bust...
John 19:33 "Here on earth you will have many trials and sorrows. But take heart, because I have overcome the world"
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I am personally not so sure about this article, suggesting not using Metformin for not IR women. Everything else I have ever read before, suggests Met to show improvements in non IR women like myself. I am totally anovulatory without Met, likewise I wouldn't have conceived my DD if I wasn't on Met. I am right now TTC #2, and I have about 40 day cycles with Met. Met has normalized my hormone levels too.
According to the study authors, women who took metformin ovulated more that the women who were given the standard treatment. Similarly, women in the combination therapy group ovulated more frequently than did the women in either the clomiphene-alone or the metformin-alone groups. *However*, as the current study revealed, an increase in ovulation did not result in more successful pregnancies and deliveries for either the metformin alone, or combination group.
"The bottom line here is that ovulation does not necessarily result in a successful pregnancy," said Coutifaris "The results suggest that an ovulation due to clomiphene is two times as likely to result in pregnancy compared to an ovulation caused by metformin."
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Hey, SoulCysters! Need to eat more veggies, but can't find recipes??
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I was on Met for almost 2 years, and my RE took me off due to normal glucose tolerance test (off met). Insulin levels are normal off met too. She said the recent studies show if you are TTC, clomid by itself is the more effective med. I'm glad to be off that stuff--I felt like it wasn't working for me anyway--Hair issues, no AF, no baby.
I took myself off metformin, the doc said I am not IR, and met was CLEARLY not working for me, but more against me. Making me feel weak and tired and just under the weather. Met didn't make me normal, loose weight, ovulate, zilch na da. And I was still growing hair! I'm doing so much better now with my current routine, I'm praying I never have to look at metformin again.
__________________ Kim-23 & Df-26-- TTC since 1/2008 Herbal Supps for now! Trusting God when it is that we conceive!
Psalms 27:14 " Wait on the Lord: be of good courage, and He shall strengthen thine heart; wait, I say, on the Lord."
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I brought my doc a very large study published that my sis in law gave me (Ph.D at FSU) and he did acknowledge that people debate using met but many in the states feel that it does help and is worth the try.
Helps what?
From a medical standpoint, that doesn't really mean anything.
Exercise 'helps' - and there's no debate or controversy there...but you don't see nearly enough women with pcos exercising the recommended 300 minutes per week - especially since they hope a 'pill' will do the job (which it won't)
The point of the article is this: While met 'helps' women ovulate, it didn't result in more successful PREGNANCIES.
And based on the review of the literature, the 'ideal' course of treatment for women ttc w/ pcos is:
Quote:
The recommended first-line treatment for ovulation induction remains the anti-estrogen clomiphene citrate (CC).
Recommended second-line intervention, should CC fail to result in pregnancy, is either exogenous gonadotrophins or laparoscopic ovarian surgery (LOS). The use of exogenous gonadotrophins is associated with increased chances for multiple pregnancy and, therefore, intense monitoring of ovarian response is required. LOS alone is usually effective in <50% of women and additional ovulation induction medication is required under those circumstances. Overall, ovulation induction (representing the CC, gonadotrophin paradigm) is reported to be highly effective with a cumulative singleton live birth rate of 72%.
Recommended third-line treatment is in vitro fertilization.
Again, those are just 'RECOMMENDATIONS', as the article also goes on to say this:
Quote:
More patient-tailored approaches should be developed for ovulation induction based on initial screening characteristics of women with PCOS.
Such approaches may result in deviation from the above mentioned first-, second- or third-line ovulation strategies in well-defined subsets of patients.
Bottom line, however, in terms of RECOMMENDED course of treatment:
Quote:
Metformin use in PCOS should be restricted to women with glucose intolerance.
Based on recent data available in the literature, the routine use of this drug in ovulation induction is not recommended.
