No. 362-Ovulation Induction in Polycystic Ovary Syndrome

Fertility treatment for people with epilepsy

Fertility treatment, including assisted reproductive technology (ART), is increasingly used. Sex hormones influence seizure control as well as interacting with antiseizure medications, and so the hormonal manipulation involved in fertility treatments has direct implications for people with epilepsy. Here, we summarise the various fertility treatments and consider their important influences on epilepsy care. While early observations raised concerns about seizure exacerbation associated with ART, there are limited data to guide best practice in people with epilepsy, and further research is needed.

Guideline No. 444: Hirsutism: Evaluation and Treatment

OBJECTIVE

This guideline reviews the etiology, diagnosis, evaluation, and treatment of hirsutism.

TARGET POPULATION

Women with hirsutism.

OPTIONS

Three approaches to management include: 1) mechanical hair removal; 2) suppression of androgen production; and 3) androgen receptor blockade.

OUTCOMES

The main limitations of the management options include the adverse effects, costs, and duration of treatment.

BENEFITS, HARMS, AND COSTS

Implementation of the recommendations in this guideline may improve the management of hirsutism in women with this condition. Adverse effects and a potential long duration of treatment are the main drawbacks to initiating treatment, as is the possibility of significant financial costs for certain treatments.

EVIDENCE

A comprehensive literature review was updated to April 2022, following the same methods as for the prior Society of Obstetricians and Gynaecologists of Canada (SOGC) Hirsutism guidelines. Results were restricted to systematic reviews, randomized controlled trials, controlled clinical trials, and observational studies. There were no date limits, but results were limited to English- or French-language materials.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, along with the option of designating a recommendation as a "good practice point." See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

Primary care providers, family medicine physicians, obstetricians and gynaecologists, reproductive endocrinologists and others who manage the care of patients with hirsutism.

TWEETABLE ABSTRACT

Management of hirsutism involves a 3-pronged approach of mechanical hair removal, suppression of androgen production, and androgen receptor blockade.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Comparison of Three Ovulation Induction Therapies for Patients With Polycystic Ovary Syndrome and Infertility

The purpose of this research was to evaluate the efficacy of 3 ovulation induction therapies for treating infertility in patients with polycystic ovary syndrome (PCOS). In this retrospective study, we compared the success rates of 90 patients who underwent intrauterine insemination, who were randomly assigned to 1 of 3 treatment groups: letrozole (LE) + urinary gonadotropin (human menopausal gonadotropin [HMG]), clomiphene (CC) + HMG, or HMG alone. Using ultrasound scanning, we examined the number of mature follicles, ovulation rate, clinical pregnancy rate, endometrial thickness, and blood flow. When compared to the other 2 groups, the LE + HMG group had significantly higher levels of mature follicles, ovulation rate, clinical pregnancy rate, estradiol, and luteinizing hormone on the day of the human chorionic gonadotropin injection and endometrial receptivity (P < .05). There was no statistically significant difference between the 3 groups in terms of abortion rate, ectopic pregnancy rate, or adverse reactions. In this research, we found that infertility in patients with PCOS could be effectively treated by combining LE with HMG. This protocol increased ovulation, boosted fertility, and enhanced endometrial receptivity with no increase in adverse reactions. Therefore, it may be a useful clinical approach for inducing ovulation and treating infertility in patients with PCOS.

The impact of a group based, remotely delivered weight loss intervention in women with polycystic ovary syndrome on ovulation, quality of life and body composition

Background

Obesity and visceral adiposity are associated with anovulation. The most common cause of anovulatory infertility in women of reproductive age is polycystic ovary syndrome (PCOS). We conducted this formative study to examine the effects of a remotely delivered, group-based lifestyle program for women with overweight/obesity and PCOS on ovulation, PCOS related quality of life (PCOSQ) and body composition.

Methods

Women with anovulatory infertility caused by PCOS (N = 12) were enrolled in a 6-month high-intensity weight management intervention. Participants were asked to attend 45 min., group behavioral lifestyle sessions, delivered remotely by a registered dietitian weekly across the 6-mo. study and comply with a reduced energy diet, increased physical activity (225 min/wk.), and self-monitoring of weight, physical activity and diet. Diets consisted of five portion-controlled meals (three shakes + two entrees), at least five servings of fruits/vegetables, and ad libitum non-caloric beverages daily. Wilcoxon signed-rank tests were used to assess changes in outcomes across the intervention.

Results

Twelve women received the weight loss intervention (mean age = 32.7 ± 4.2 yrs., BMI = 36.8 ± 4.5 kg/m², 92% college educated), and 8 completed the intervention. Eight (67%) women reported ovulating during the intervention with an average time to ovulation of 57 ± 45 days. Women lost an average of 3.85 ± 5.94 kg (p = 0.02), decreased their BMI (−1.61 ± 1.09 kg/m²; p = 0.04), and waist circumference (−4.54 ± 3.03 cm; p = 0.04) over the 6-mo. intervention. Additionally, self-reported menstrual problems measured by PCOSQ significantly improved over the study (p = 0.03).

Conclusion

A multicomponent group-based, remotely delivered, lifestyle intervention delivered remotely is a feasible and potentially scalable option to achieve clinically relevant (>3%) weight loss in women with PCOS.

Clinical trial registration

www.clinicaltrials.gov, identifier: NCT03677362.

Polycystic Ovary Syndrome and Incidental Diagnosis of Mosaic Turner Syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common condition in women of reproductive age. Mosaic Turner syndrome (TS) is a genetic disorder with significant phenotypic variability. The occurrence of PCOS in women with mosaic TS has been infrequently studied.

CASE

A 30-year-old nulligravid woman presented with oligomenorrhea, hyperandrogenism, infertility, and ultrasound polycystic ovary morphology. She was diagnosed with PCOS and conceived following ovulation induction. After 2 inconclusive non-invasive prenatal screening results, she was referred to medical genetics. A maternal karyotype resulted in a diagnosis of 45,X/46,XX mosaic TS. She delivered a healthy 46,XY infant at term.

CONCLUSION

PCOS can affect women with mosaic TS. Further studies are needed to better characterize the reproductive profile of women with mosaic TS, including the presentation of concurrent PCOS.

A rare case of heterotopic quintuplets pregnancy

OBJECTIVE

We report a rare case of heterotopic pregnancy and high-order pregnancy occurring simultaneously following the use of the assisted reproductive technique (ART).

CASE REPORT

A 29-year-old woman, Gravida 2 Para 1, became pregnant after receiving intrauterine insemination (IUI). She came to our emergency room due to diffuse low abdominal pain at seven weeks of gestational age. Transabdominal sonography (TAS) revealed a quadruplet intrauterine pregnancy with an enlarged left adnexa and intrapelvic fluid accumulation. Simultaneous occurrence of high-order pregnancy and left tubal pregnancy with internal hemorrhage was suspected. The patient received an emergent laparoscopic resection of the affected Fallopian tube and recovered well for the remaining hospitalization course. Afterwards, she received fetal reduction procedure and eventually gave birth to twin babies.

CONCLUSION

Gynecologist should increase the awareness of heterotopic pregnancy in patients receiving ART. On the other hand, reproductive endocrinologist should reduce the risk of high-order pregnancy without compromising pregnancy rate.