Use of community-based reference ranges to estimate the prevalence of polycystic ovary syndrome by the recognised diagnostic criteria, a cross-sectional study

Fertility treatment pathways and births for women with and without polycystic ovary syndrome-a retrospective population linked data study

OBJECTIVE

To study the fertility treatment pathways used by women with and without polycystic ovary syndrome (PCOS) and which pathways were more likely to result in a birth.

DESIGN

This retrospective national community-based cohort study used longitudinal self-report survey data (collected 1996-2022; aged 18-49 years) from women born in 1973-1978 who are participants in the Australian Longitudinal Study on Women's Health. The study also used linked administrative data on fertility treatments (1996-2021).

PATIENTS

Of the 8,463 eligible women, 1,109 accessed fertility treatment and were included.

EXPOSURE

Polycystic ovary syndrome diagnosis was self-reported.

MAIN OUTCOME MEASURE

use of ovulation induction (OI), intrauterine insemination, and/or in vitro fertilization (IVF) was established through linked administrative data. Births were self-reported.

RESULTS

One in 10 of the eligible participants had PCOS (783/7,987, 10%) and 1 in 4 of the women who used fertility treatment had PCOS (274/1,109, 25%). Women with PCOS were 3 years younger on average at first fertility treatment (M = 31.4 years, SD = 4.18) than women without PCOS (M = 34.2 years, SD = 4.56). Seven treatment pathways were identified and use differed by PCOS status. Women with PCOS were more likely to start with OI (71%; odds ratio [OR] 4.20, 95% confidence interval [CI]: 2.91, 6.07) than women without PCOS (36%). Of the women with PCOS who started with OI, 46% required additional types of treatment. More women without PCOS ended up in IVF (72% vs. 51%). Overall, 63% (701/1,109) had an attributed birth, and in adjusted regressions births did not vary by last type of treatment (IVF: 67%, reference; intrauterine insemination: 67%, OR 0.94 95% CI: 0.56, 1.58; OI: 61%, OR 0.71, 95% CI: 0.52, 0.98), or by PCOS status (OR 1.27, 95% CI: 0.91, 1.77). By age, 74% of women under 35 years (471/639) and 49% of women 35 years or older had a birth.

CONCLUSION

More women with PCOS used fertility treatment but births were equivalent to women without PCOS. Most women followed clinical recommendations. Births did not differ between pathways, so there was no disadvantage in starting with less invasive treatments (although there may be financial or emotional disadvantages).

Examining the co-occurrence of endometriosis and polycystic ovarian syndrome

BACKGROUND

Polycystic ovarian syndrome and endometriosis are 2 of the most common reproductive disorders among women but are thought to be unrelated.

OBJECTIVE

This study aimed to examine the overlap and common symptoms of polycystic ovarian syndrome and endometriosis.

STUDY DESIGN

The study population included the Endometriosis, Natural History, Diagnosis, and Outcomes Study (2007-2009) operative cohort: 473 women, aged 18 to 44 years, who underwent a diagnostic and/or therapeutic laparoscopy or laparotomy at 1 of 14 surgical centers located in Salt Lake City, Utah, or San Francisco, California, in addition to a population cohort composed of 127 women from the surgical centers' catchment areas. Age and site-adjusted multinomial regression models were used to estimate adjusted prevalence ratios and 95% confidence intervals of reproductive history characteristics among women with endometriosis only, women with polycystic ovarian syndrome only, and women with both endometriosis and polycystic ovarian syndrome.

RESULTS

Among the operative cohort, 35% had endometriosis only, 9% had polycystic ovarian syndrome only, and 5% had endometriosis and polycystic ovarian syndrome. Among the population cohort, 10% had endometriosis only, 8% had polycystic ovarian syndrome only, and 2% had endometriosis and polycystic ovarian syndrome. In the operative cohort, a history of subfertility was associated with a higher adjusted probability of having both conditions (adjusted prevalence ratio, 10.33; 95% confidence interval, 3.94-27.08), followed by having endometriosis only (adjusted prevalence ratio, 2.45; 95% confidence interval, 1.56-3.84) or polycystic ovarian syndrome only (adjusted prevalence ratio, 1.15; 95% confidence interval, 0.51-2.61), than having neither condition. In addition, experiencing chronic pelvic pain within the past 12 months was associated with a higher probability of having both conditions (adjusted prevalence ratio, 2.53; 95% confidence interval, 1.07-6.00) than having neither condition.

CONCLUSION

Among a cohort of women undergoing gynecologic laparoscopy or laparotomy, our study found that nearly 1 in 20 women had both an incident endometriosis diagnosis and symptoms consistent with polycystic ovarian syndrome. Among a population cohort of women not seeking gynecologic care, polycystic ovarian syndrome and endometriosis overlap prevalence was approximately 1 in 50 women.

AMH as part of the diagnostic PCOS workup in large epidemiological studies

OBJECTIVES

Previous studies have shown good correlation between polycystic ovarian morphology (PCOM) and serum anti-Müllerian hormone (AMH) levels. We evaluated the utility of AMH as a surrogate for PCOM as a part of the polycystic ovary syndrome (PCOS) diagnosis by describing how the use of different AMH cut-off values would change the prevalence of PCOS.

METHODS

A general population-based birth cohort study. Anti-Müllerian hormone concentrations were measured from serum samples taken at age 31 years (n = 2917) using the electrochemiluminescence immunoassay (Elecsys). Anti-Müllerian hormone data were combined with data on oligo/amenorrhoea and hyperandrogenism to identify women with PCOS.

RESULTS

The addition of AMH as a surrogate marker for PCOM increased the number of women fulfilling at least two PCOS features in accordance with the Rotterdam criteria. The prevalence of PCOS was 5.9% when using the AMH cut-off based on the 97.5% quartile (10.35 ng/mL) and 13.6% when using the recently proposed cut-off of 3.2 ng/mL. When using the latter cut-off value, the distribution of PCOS phenotypes A, B, C, and D was 23.9%, 4.7%, 36.6%, and 34.8%, respectively. Compared with the controls, all PCOS groups with different AMH concentration cut-offs showed significantly elevated testosterone (T), free androgen index (FAI), luteinizing hormone (LH), LH/follicle-stimulating hormone (FSH) ratio, body mass index (BMI), waist circumference, and homoeostatic model assessment of insulin resistance (HOMA-IR) values, as well as significantly decreased sex hormone-binding globulin (SHBG) values.

CONCLUSIONS

Anti-Müllerian hormone could be useful surrogate for PCOM in large data sets, where transvaginal ultrasound is not feasible, to aid the capturing of women with typical PCOS characteristics. Anti-Müllerian hormone measurement from archived samples enables retrospective PCOS diagnosis when combined with oligo/amenorrhoea or hyperandrogenism.

Does the risk of embryo abnormality increase in PCOS women? A secondary analysis of a multi-center randomized controlled trial

CONTEXT

Some studies reported the early miscarriage rate was higher in PCOS women. However, whether the risk of embryo abnormalities increases in PCOS women is lack of evidence.

OBJECTIVE

To evaluate the association between polycystic ovarian syndrome (PCOS) and embryo ploidy.

DESIGN

A secondary analysis of multi-center randomized controlled trial which was conducted from July 2017 to June 2018. The original intent was to identify whether preimplantation genetic test for aneuploidy (PGT-A) improves the live birth rate as compared with in-vitro fertilization (IVF).

SETTING

14 reproductive centers.

PATIENTS

190 patients diagnosed with PCOS and 1:1 age-matched non-PCOS patients were chosen from PGT-A group. A total of 380 patients with 1118 embryos were included in our study.

INTERVENTIONS

Women diagnosed with PCOS.

MAIN OUTCOME MEASURES

Embryonic aneuploidy and embryonic mosaic.

RESULTS

After adjusted for potential confounders, the rate of embryonic aneuploidy and embryonic mosaic in PCOS group were comparable with control group [embryonic aneuploid rate PCOS group: 14.0% vs control group: 18.3%, adjusted OR (95%CI): 0.78(0.54,1.12), P = 0.19; embryonic mosaic rate 10.9% vs 10.1%, adjusted OR (95%CI): 0.91(0.59,1.40), P = 0.66]. We further stratified PCOS women into four groups according to phenotype. The rate of aneuploid and mosaic embryos was comparable between each of PCOS phenotype and control group. There was still no significant difference of embryonic aneuploid and embryo mosaic rates within four phenotypes.

CONCLUSIONS

The risk of aneuploid and mosaic embryos was not increased in PCOS women. Thus, we suggests that the miscarriage rate arising from abnormal embryonic chromosomes could be similar between PCOS and non-PCOS women.

Prevalence of polycystic ovary syndrome in patients with type 2 diabetes: A systematic review and meta-analysis

PURPOSE

With type 2 diabetes mellitus (T2DM) occurring at a younger age, a greater number of women with T2DM experience reproductive health problems. The prevalence of polycystic ovary syndrome (PCOS), a common reproductive disease associated with T2DM, remains unknown in women with T2DM. This systematic review and meta-analysis aimed to determine the prevalence of PCOS in women with T2DM.

METHODS

Stata 15.1 was used to perform a meta-analysis on the prevalence of PCOS in patients with T2DM included in this study. Additionally, a narrative review of the effects of different diagnostic methods, obesity, state, and other factors on the prevalence of PCOS was conducted.

RESULTS

Meta-analysis showed that the overall prevalence of PCOS in women with T2DM was approximately 21%. Subgroup analysis showed that the incidence of PCOS in female patients aged 25-45 years was higher than that in female patients aged < 25 years. The prevalence of PCOS in obese women was 14%, which was lower than that in normal weight women and normal weight or overweight or obese women. Women with T2DM in Oceania had the highest incidence of PCOS, followed by those in Europe and Asia; women with T2DM in North America had the lowest incidence. In terms of PCOS diagnostic standards, the prevalence of PCOS diagnosed by the National Institutes of Health was the lowest. The prevalence of PCOS diagnosed on the basis of clinical symptoms and biochemical characteristics was the highest, and the prevalence of PCOS diagnosed on the basis of medical records was 20%.

CONCLUSIONS

PCOS is a common disease in female patients with T2DM. The prevalence of PCOS in women with T2DM at childbearing age was higher than that in adolescent females. Women with T2DM at childbearing age should pay attention to the screening and prevention of PCOS to avoid the hazards of PCOS to reproductive health.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, identifier CRD42022318657.

Substituting serum anti-Müllerian hormone for polycystic ovary morphology increases the number of women diagnosed with polycystic ovary syndrome: a community-based cross-sectional study

STUDY QUESTION

Can serum anti-Müllerian hormone (AMH) replace polycystic ovary morphology (PCOM) determined by ultrasound as a diagnostic component of polycystic ovary syndrome (PCOS)?

SUMMARY ANSWER

Despite good correlations between serum AMH and PCOM, the use of a high serum AMH as a proxy for PCOM resulted in the reclassification of PCOS in 5% of study participants, with the main effect being more women identified, although some women previously classified as having PCOS were no longer classified as such.

WHAT IS KNOWN ALREADY

AMH has been proposed as an alternative to PCOM as a diagnostic component of PCOS. Previous studies are limited by poorly defining PCOS, use of infertile women as comparators, measurement of hormones by immunoassay that lack precision in the female range, low-resolution ovarian ultrasound and inconsistent handling and storage of serum samples.

STUDY DESIGN, SIZE, DURATION

This is an Australian cross-sectional study of 163 non-healthcare-seeking women.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Serum AMH was measured by both the Ansh picoAMH assay and the Beckman Coulter Access 2 (BA2) assay, in parallel with androgens measured by liquid chromatography-tandem mass spectrometry, in blood samples of women, not pregnant, breast feeding or using systemic steroids, who also underwent high-resolution ovarian ultrasound. PCOS was determined by the Rotterdam criteria with PCOM defined by the Androgen Excess-PCOS Taskforce recommendation of ≥25 follicles in at least one ovary. Cut-off serum concentrations that best identified women as having PCOM were identified by receiver operator characteristic (ROC) curves.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 163 women, mean (SD) age 32.5 (5.5) years, who provided a blood sample and had both ovaries visualized on ultrasound were included in the analysis. Women with isolated PCOM had higher median (range) Ansh AMH and BA2 AMH concentrations than those with no PCOS characteristics [56.9 pmol/l (34.6, 104.2) versus 18.7 (3.2, 50.9), P = 0.002 and 38.5 pmol/l (22.2, 100.2) versus 16.7 (3.5, 38.9), P = 0.002, respectively]. An AMH ≥ 44.0 pmol/l, suggested by the ROC curve, identified 80.6% of women with PCOM, falsely identified 15.2% of women without PCOM as having PCOS and had a positive predictive value of 55.6%. The negative predictive value was 94.9%. An AMH BA2 assay cut-off of ≥33.2 pmol/l provided a sensitivity of 80.6%, a specificity of 79.5% and a positive predictive value for PCOM of 48.1%. The negative predictive value was 94.6% for PCOM. When serum AMH was used in the place of PCOM as a diagnostic criterion for PCOS, the Ansh assay resulted in an additional seven women classified as having PCOS and no longer classified one woman as having PCOS. For the BA2 assay, eight additional and two fewer women were classified as having PCOS. Overall, both assays resulted in six more women being classified as having PCOS.

LIMITATIONS, REASONS FOR CAUTION

Women with functional hypogonadotrophic hypogonadism were not excluded and may have been misclassified as having an oligo-amenorrhoea-PCOM phenotype. As study participants were predominantly Caucasian/White, our findings cannot be generalized to women of other ethnicities.

WIDER IMPLICATIONS OF THE FINDINGS

Although serum AMH reflects the number of developing ovarian follicles, the absolute values vary between assays and specific reference ranges for individual assays are required. Irrespective of the assay used, replacing PCOM with serum AMH to diagnose PCOS in a community-based sample altered the number of women classified as having or not having PCOS. Consequently, although overall the risk of women being identified as having PCOS would be increased, some women would no longer be classified as having this condition.

STUDY FUNDING/COMPETING INTEREST(S)

The study was supported by the Norman Beischer Research Foundation and the Grollo-Ruzzene Foundation. S.R.D. is an NHMRC Senior Principal Research Fellow (Grant No. 1135843). S.R.D. reports unrelated support that includes grants from the NHMRC Australia, personal fees for educational activities from Besins Healthcare, Abbott Chile, BioFemme and Pfizer Australia, personal Advisory Board/consultancy fees from Theramex, Abbott Laboratories, Astellas, Mayne Pharmaceuticals, Roche Diagnostics, Lawley Pharmaceuticals and Que Oncology and has received institutional grant funding from Que Oncology and Ovoca research. The other authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.