| from the book How to Have a Baby: Overcoming
Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani,
MD.
Previous page:
The Older Woman (Page 2)
Next page: The
Cervical Factor
Table of Contents
What
is PCOD ( polycystic ovarian disease) ?
How
is PCOD diagnosed ?
What
is the cause of PCOD ?
What
is occult PCOD ?
How
is PCOD treated ?
How
can ovulation be induced in patients with PCOD ?
How
is surgery used to treat patients with PCOD ?
How
is IVF used for treating patients with PCOD ?
What is PCOD ( polycystic
ovarian disease) ?
Patients suffering from polycystic ovarian
disease ( PCOD ) have multiple small cysts in their
ovaries ( the word poly means many). These cysts occur
when the regular changes of a normal menstrual cycle
are disrupted. The ovary is enlarged; and produces excessive
amounts of androgen and estrogenic hormones. This excess,
along with the absence of ovulation, may cause infertility.
Other names for PCOD are polycystic ovarian syndrome
(PCOS) or the Stein-Leventhal syndrome.
How
is PCOD diagnosed ?
PCOD can be easy to diagnose in some patients. The typical
medical history is that of irregular menstrual cycles,
which are unpredictable and can be very heavy ; and
the need to take hormonal tablets (progestins) to induce
a period. Patients suffering from PCOD are often obese
and may have hirsutism , (excessive facial and body
hair) as a result of the high androgen levels. However,
remember that not all patients with PCOD will have all
or any of these symptoms.
This diagnosis can be confirmed by vaginal
ultrasound, which shows that both the ovaries are enlarged;
the bright central stroma is increased ; and there are
multiple small cysts in the ovaries. These cysts are
usually arranged in the form of a necklace along the
periphery of the ovary. ( It is important that your
doctor be able to differentiate multicystic ovaries
from polycystic ovaries. )
Blood tests are also very useful for
making the diagnosis. Typically, blood levels of hormones
reveal a high LH ( luteinising hormone) level;
and a normal FSH ( follicle stimulating hormone) level
( this is called a reversal of the LH : FSH ratio, which
is normally 1:1); and elevated levels of androgens (
a high dehydroepiandrosterone sulphate ( DHEA-S)
level) ;
Fig 1. A schematic, comparing a polycystic ovary with
a normal ovary.
What
is the cause of PCOD ?
We don't really understand what causes
PCOD, though we do know that it has a significant hereditary
component, and is often transmitted from mother to daughter
. We also know that the characteristic polycystic ovary
emerges when a state of anovulation persists for a length
of time. Patients with PCO have persistently elevated
levels of androgens and estrogens, which set up a vicious
cycle. Obesity can aggravate PCOD because fatty tissues
are hormonally active and they produce estrogen which
disrupts ovulation . Overactive adrenal glands can also
produce excess androgens, and these may also contribute
to PCOD. These women also have insulin resistance (
high levels of insulin in their blood, because their
cells do not respond normally to insulin).
Fig 2. The self-perpetuating vicious cycle of elevated
levels of androgens and estrogens in PCOD
What
is occult PCOD ?
While some women with PCOD will
have all the classic symptoms and signs, many have what
we call "occult PCOD". This means that they may be thin,
have regular periods , no hirsutism and normal looking
ovaries on ultrasound, but still have PCOD. This problem
is detected only when these patients are superovulated,
at which time they over-respond by producing a large
number of follicles.
Interestingly, many of these patients
present with
recurrent pregnancy loss ( recurrent miscarriages)
, and often their doctor does not make the correct diagnosis
for them.
How
is PCOD treated ?
Treatment of PCOD for the infertile patient will usually
focus on inducing ovulation to help them conceive.
Weight loss: For many patients
with PCOD, weight loss is an effective treatment - but
of course, this is easier said than done! Look for a
permanent weight loss plan - and referral to a dietitian
or a weight control clinic may be helpful. Crash diets
are usually not effective.
Increasing physical activity is an important
step in losing weight. Aerobic activities such as walking,
jogging or swimming are advised. Try to find a partner
to do this with, so that you can help each other to
keep going.
How can
ovulation be induced in patients with PCOD ?
Ovulation Induction: The drug
of first choice for women with PCOD today is metformin
( this medicine is also used for treating patients with
diabetes. ) Doctors have now learned that many patients
with PCOD also have insulin resistance – a condition
similar to that found in diabetics, in that they have
raised levels of insulin in their blood ( hyperinsulinemia)
, and their response to insulin is blunted. This is
why some patients with PCOD who do not respond to clomiphene
are treated with antidiabetic drugs, such as metformin
and troglitazone. Studies have shown that these drugs
improve their fertility by reversing their endocrine
abnormality and improving their ovulatory response.
In the past, the drug of first choice
used to be clomiphene; this may be combined with low-doses
of dexamethasone, a steroid which suppresses androgen
production from the adrenal glands. Just taking clomiphene
is not enough , and you need to be monitored ( usually
with ultrasound scans) to determine if the clomiphene
is helping you to ovulate or not. The doctor may have
to progressively increase the dose till he finds the
right dose for you. If clomiphene does not work, a newer
anti-estrogen called letrozole ( which is also used
for treating women with breast cancer) can be used.
Clomiphene resistant PCO women may need ovulation induction
with HMG ( gonadotropins). Some doctors prefer to use
pure FSH for inducing ovulation in PCOD patients because
they have abnormally high levels of LH.
Ovulation induction can often be difficult
in patients with PCOD , since there is the risk that
the patient may over-respond to the drugs, and produce
too many follicles, which is why the risk of ovarian
hyperstimulation syndrome ( OHSS) and multiple pregnancy
is often increased in patients with PCOD. The doctor
has to find just the right dose of HMG ( called the
threshold value ) in order to induce maturation and
release of a single , or only a few follicles , and
this can sometimes be very tricky.
Difficult patients may also need a combination
of a GnRH analog (to stop the abnormal release of FSH
and LH from the pituitary) and HMG to induce ovulation
successfully.
How is surgery
used to treat patients with PCOD ?
Surgery: A recent treatment option
uses laparoscopy to treat patients with PCOD. During
operative laparoscopy, a laser or cautery is used to
drill multiple holes through the thickened ovarian capsule.
This procedure is called laparoscopic ovarian cauterisation
or ovarian drilling or LEOS ( laparoscopic electrocauterisation
of ovarian stroma) . This should be reserved for women
with PCOD who have large ovaries with increased stroma
on ultrasound scanning. Destroying the abnormal ovarian
tissue helps to restore normal ovarian function and
helps to induce ovulation. For young patients with PCO
ovaries on ultrasound, if clomiphene fails to achieve
a pregnancy in 4 months time, we usually advise laparoscopic
surgery as the next treatment option. This is
because LEOS helps us to correct the underlying problem;
and about 80% of patients will have regular cycles after
undergoing this surgery, of which 50% will conceive
in a year’s time, without having to take further medication
or treatment. Having regular cycles without having to
take medicines each month can be very reassuring to
these patients !
The skill of the surgeon plays a key
role in determining the outcome of the surgery . It
is important that the surgeon selectively destroy only
the stroma, and NOT the cortex. The cortex of the ovary
contains the eggs, and if this damaged, then ovarian
function is jeopardised, so that the surgery may actually
end up causing infertility ! An additional risk of this
surgery is that it can induce adhesion formation, if
not performed competently.
In the past, doctors used to perform
ovarian surgery called wedge resection to help patients
with PCOD to ovulate. The removal of the abnormal ovarian
tissue in the wedge breaks the vicious cycle of PCOD,
helping ovulation to occur . While wedge resection used
to be a popular treatment option, the risk of inducing
adhesions around the ovary as a result of this surgery
has led to the operation being used as a last resort.
For patients who do not respond to the
above measures, ovulation induction plus intrauterine insemination
is the next step.
How is IVF
used for treating patients with PCOD ?
If 3 cycles of IUI have
failed, then IVF is the best treatment option for patients
with PCOD. However, many IVF clinics have little experience
in superovulating these women, and they often mess up
their superovulation. Because these women grow so many
eggs in response to the HMG injections used for superovulation,
and because doctors are very worried about the risk
of ovarian hyperstimulation, they often end up triggering
egg collection with HCG when the eggs are immature.
They consequently get lots of eggs, but since most of
these are immature, fertilisation rates and pregnancy
rates are very poor.
In our clinic, because
we have extensive experience in dealing with women with
PCOD ( which is much commoner in the Middle East and
South India than in the West), we do a much better job
at getting these women to grow many mature eggs. Also,
because we carefully and meticulously flush each and
every follicle at the time of egg collection, the risk
of PCOD patients developing ovarian hyperstimulation
in our clinic has been virtually zero in the last 8
years.
The good news is that with the currently
available treatment options, successful treatment of
the infertility is usually possible in the majority
of patients with PCOD.
Next page: The
Cervical Factor
Previous page:
The Older Woman (Page 2)
Table of Contents
|
