Polycystic ovary syndrome (PCOS) is a common endocrine and reproductive disorder that affects a significant percentage of women of reproductive age. The condition is characterized by various symptoms, including hyperandrogenism (an excess of male hormones), oligo-anovulation (infrequent or absent menstrual periods), and multiple small cysts on the ovaries. These symptoms can lead to a range of clinical and metabolic disorders and are often associated with infertility.
When a couple has been trying to conceive for six months without success and has regular sexual intercourse (2 to 3 times/week) without using contraceptive methods, the American Society for Reproductive Medicine recommends that infertility evaluation should begin. The evaluations of tubal patency (hysterosalpingography or laparoscopy with chromotubation) and semen analysis are mandatory to optimize the efficacy of treatment for infertile women with PCOS. However, tubal patency evaluation may not be necessary prior to initiating clomiphene citrate (CC) treatment. It is noteworthy that if a patient is resistant to this drug and/or requires the use of gonadotropins and/or presents with other causes of infertility, a tubal patency evaluation becomes mandatory prior to initiating therapeutic treatment.
Lifestyle change is considered the first-line treatment for infertility in obese women with PCOS. Preconception counseling, physical activity, and identification of risk factors such as obesity, tobacco use, and alcohol consumption should be performed. Weight loss, regardless of body mass index, may be associated with improvement in central obesity, hyperandrogenism, and ovulation rate. However, no studies with the proper methodology have assessed the live birth rate, which is the primary reproductive outcome. In addition to improving reproductive and metabolic factors, the reduction in body weight may be associated with a reduced incidence of complications during pregnancy and the neonatal period.
The principle infertility treatment initially includes preconception guidelines and the use of drugs to induce mono- or bifollicular ovulation. Clomiphene citrate or Letrozole are the first-line treatments for anovulatory women with PCOS. These drugs help to stimulate ovulation, which is the process of releasing an egg from the ovary.
If the first-line treatment is ineffective, other therapeutic modalities may be employed. Second-line treatments such as exogenous gonadotropins or laparoscopic ovarian drilling can be considered. Gonadotropins like recombinant follicle-stimulating hormone (FSHr) or human menopausal gonadotropin (HMG) are used for timed intercourse or intrauterine insemination (IUI). Laparoscopic ovarian drilling is an invasive technique that involves puncturing the ovary with a monopolar electrocautery device. This technique is used in cases of anovulatory women with CC-resistant PCOS who require laparoscopy for another reason.
In vitro fertilization (IVF) represents the third-line treatment for infertility in women with PCOS. However, if the initial evaluation demonstrates a bilateral tubal occlusion and/or concentration of recovered motile sperm less than or equal to 5 million, this treatment becomes the first option along with lifestyle changes. The main complication of IVF treatment in women with PCOS is ovarian hyperstimulation syndrome (OHSS), which can cause swelling and pain in the ovaries, nausea, and vomiting. Careful monitoring and management of medication doses are essential to minimize the risk of OHSS.
The choice of the most appropriate treatment depends on various factors, including the patient’s age, presence of other factors associated with infertility, experience and duration of previous treatments, and the level of anxiety of the couple.