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Toronto Notes 2019 Polycystic Ovarian Syndrome
■ ovulationinduction
◆ clomiphene citrate (Clomid®): estrogen antagonist causing a perceived decreased estrogen
state, resulting in increased pituitary gonadotropins; which increases FSH and LH and induces
ovulation (better results if anovulatory)
◆ followed by β-hCG for stimulation of ovum release
◆ Letrozole: aromatase inhibitor. May be associated with a higher rate of live births in patients with
PCOS ■ may add:
◆ bromocriptine (dopamine agonist) if elevated prolactin
◆ dexamethasone for hyperandrogenism (adult onset congenital adrenal hyperplasia)
◆ metformin (for PCOS)
◆ luteal phase progesterone supplementation for luteal phase defect (mechanism not completely
understood)
◆ anticoagulation and ASA (81 mg PO OD) for women with a history of recurrent spontaneous
abortions (for antiphospholipid antibody syndrome) ◆ thyroid replacement to keep TSH <2.5
• surgical/procedural ■ tubuloplasty
■ lysis of adhesions
■ artificial insemination: intracervical insemination (ICI), intrauterine insemination (IUI),
intrauterine tuboperitoneal insemination (IUTPI), intratubal insemination (ITI)
■ spermwashing
■ IVF ( fertilization)
■ IFT(intrafallopiantransfer)
■ GIFT* (gamete intrafallopian transfer): immediate transfer with sperm after oocyte retrieval ■ ZIFT* (zygote intrafallopian transfer): transfer after 24 h culture of oocyte and sperm
■ TET* (tubal embryo transfer): transfer after >24 h culture
■ ICSI (intracytoplasmic sperm injection)
■ IVM(invitromaturation)
■ ±oocyteorspermdonors
■ ± pre-genetic screening for single gene defects in karyotype of zygote
Gynecology GY23
*not performed in Canada
Male Factors
• seeUrology,U35
Etiology
• varicocele(>40%)
• idiopathic(>20%)
• obstruction(~15%)
• cryptorchidism(~8%) • immunologic(~3%)
Investigations
• semenanalysisandculture
• postcoital(Huhner)test:rarelydone
Polycystic Ovarian Syndrome
Normal Semen Analysis (WHO lower reference limits)
• Must be obtained after 2-7 d of
abstinence
• Volume 1.5 cc
• Count 15 million/cc
• Vitality 58% live
• Motility 32% progressive, 40% total
(progressive + non-progressive) • Morphology 4.0% normal
Polycystic Ovarian Syndrome – HAIR-AN Hirsutism, HyperAndrogenism, Infertility, Insulin Resistance, Acanthosis Nigricans
• alsocalledchronicovarianandrogenism
Etiology
􏰁estrogen
Insulin
􏰀FSH secretion +􏰁LH secretion
􏰁ovarian secretion of androgens
Hirsutism
Anovulation
Oligomenorrhea
Infertility
􏰁peripheral conversion to estrogen
Obesity
Figure 12. Pathophysiology of polycystic ovarian syndrome