Pc o .

DR G A RAMA RAJU.

Krishnaivf

PCOS .WOMB TO TOMB

Lecture outlineDiagnostic work up.

Implication for health.

Implication for infertility.

Implication for pregnancy.

Diagnostic pcos criteria

hyeperandrogenism

Oligo/amenorrhea

POS

NIH Rott Cons AES

• To diagnose pcos the following are needed

• A C O G p r a c t i c e b u l l e t i n , O G , o c t 2 0 0 9

• Physical exam.• Laboratory• Ultrasound• Optional test

Physical.

• Blood pressure.

• BMI.

• Waist circumference.

• Presence of stigmata

hyperandrogenism.

A C O G p r a c t i c e b u l l e t i n , O G , o c t 2 0 0 9

laboratory• TSH.• Prl.• 17-0hprog• Consider screening for Cushing and

acromegaly• Evaluation metabolic abnormalities.• Fasting Lipid and lipoprotein levels

A C O G p r a c t i c e b u l l e t i n , O G , o c t 2 0 0 9

• Ultrasound

A C O G p r a c t i c e b u l l e t i n , O G , o c t 2 0 0 9

Optional tests

• Gonadotrophins

• Fasting Ins in young women

• 14h urinary free cortisol

A C O G p r a c t i c e b u l l e t i n , O G , o c t 2 0 0 9

Morphology 1935

Syndrome 1963

Endocrinology 1980

Ultrasound 1988

Metabolic 1990

45% metabolic syndrome

70 % 0besity

60% insulin resistance

Blood pressure >130/85

Abdominal obesity

triglycerides >150

Hdl cholesterol < 50 mg/dl

Faasting glucose >110 mg /dl

What is Metabolic syndrome

Metabolic syndrome marker for cardiovascualr disease

Blood pressure

Central obesity

Insulin resistance

Dyslipedemia

a condition requiring life long attention.

Reproductive disorder

Metabolic disorder

15 yrs……………………… 60 yrs

Implication for future health

Pcos follow up studies

• More diabetes , hypertension and

• cerebro vascular disease

24

INCREASED INCIDENCE OF OBESITY

Cardio vascular risk.

• Gender

• Age

• Systolic pressure

• Smoking

• Cholesterol

• ROLE AND RESPONSIBILITY OF THE

DOCTOR IN PCO

– HEALTH PRECAUTION

– HEALTH EDUCATION

– TREATMENT

IMPLICATION FOR INFERTILITY

• Optimal treatment of PCOS has not been identified

Life style modification

DIET

500 kcal/day deficit with reduced glycemic load

Life style modification

• Attention to weight and metabolic syndrome.

• Should happen before treatment

First line of drug

• Clomiphene citrate

Ovulation rate 73 % and pregnancy rate 37 %

50 yrs ago

Starting dose 50 – to 150 mg

Ovulation and

Pregnancy(6cycle)

Ovulation /Nopregnancy

(laproscopy/letrizole/gonadotrophin male factor)

No response

issues

Clomiphene citrate

Age

Dose

Monitoring

75% OVULATION RATE

DURATION

COMBINATION NO ADDITIOAL BENEFITS

Obesity

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

Second line of treatment

• Gonadotropin

• Laparoscopy ovarian drilling

AN operation which became obsolete

Laparoscopic ovarian drilling

Laparoscopy ovarian drilling

• Cc resistance

• Women needing laparoscopy .

• (best for normal bmi ,shorter duration of infertility)

GONADOTROPHIN VS DRILLING

Where does metformin fit

• Glucose intolerance.

• Role in obese > 35 .

• CC resistance.

In 2006 2 large RCT did not show any benifit

Gonadotropin therapy

Step up Step down

Avoid multiple follicle and hyperstimulation

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.

DURATION OF GONADOTROPIN THERAPY

INTENSE OVARIAN RESPONSE MONITORING

STRICT CYCLE CANCELLATION CRITERIA.

LETRIZOLECC FAILURE

CC RESISTANCE

NOT A FIRST LINE OF TREATMENT

Third line of management

• Assisted reproduction: IVF

Implication for pregnancy

GESTATIONAL DIABETES

20 T0 24 WEEKS GLUCOSE SCREEN

PREGNANCY INDUCED HYPERTENSION

BP / URINE ALBUMIN

PRETERM AND PCOS

ASSESMENT OF CERVIX AND PRECUATIONS

Birth weight

NICU ADMISSION

PERINATAL MORBIDTY

Higher nicu admission

Copyright restrictions may apply.

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

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

weight

Ehrmann D. N Engl J Med 2005;352:1223-1236

Diagnostic Algorithm for the Polycystic Ovary Syndrome

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.

THANK YOU