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Difficult patients may also need a combination of a GnRH analog (to stop the abnormal release of FSH and LH from the pituitary) and HMG to induce ovulation successfully. Doctors have now learned that many patients with PCOD also have insulin resistance - a condition similar to that found in diabetics, in that they have raised levels of insulin in their blood (hyperinsulinemia), and their response to insulin is blunted. This is why some patients with PCOD who do not respond to clomiphene are treated with antidiabetic drugs, such as metformin. Studies have shown that these drugs can help to improve their fertility by reversing their endocrine abnormality and thus improving their ovulatory response.
A recent treatment option uses laparoscopy to treat patients with PCOD. During operative laparoscopy, a laser or cautery is used to drill multiple holes through the thickened ovarian capsule. This procedure is called laparoscopic ovarian cauterisation or ovarian drilling or LEOS (laparoscopic electrocauterisation of ovarian stroma). Destroying the abnormal ovarian tissue helps to restore normal ovarian function and helps to induce ovulation. For young patients with PCO ovaries on ultrasound, if clomiphene fails to achieve a pregnancy in 4 months' time, we usually advise laparoscopic surgery as the next treatment option. This is because LEOS helps us to correct the underlying problem, and about 80% of patients will have regular cycles after undergoing this surgery, of which 50% will conceive in a year's time, without having to take further medication or treatment. Having regular cycles without having to take medicines each month can be very reassuring for these patients! The risk of this surgery is that it can induce adhesion formation, if not performed competently.
In the past, doctors used to perform ovarian surgery called wedge resection to help patients with PCOD to ovulate. The removal of the abnormal ovarian tissue in the wedge breaks the vicious cycle of PCOD, helping ovulation to occur. While wedge resection used to be a popular treatment option, the risk of inducing adhesions around the ovary as a result of this surgery has led to the operation being used as a last resort.
For patients who do not respond to the above measures, intrauterine insemination is the next step. Some difficult patients with PCOD may also need IVF in order to get pregnant. While PCOD patients usually grow many eggs, quite a few of these may be immature, so that fertilization rates may be lower than average. Also, because of the PCOD, the risk of ovarian hyper stimulation syndrome is increased in these patients.
The good news is that with the currently available treatment options, successful treatment of the infertility is usually possible in the majority of patients with PCOD.
© Dr. Aniruddha Malpani and Dr. Anjali Malpani www.drmalpani.com
Credits: How to Have a Baby: Overcoming Infertility
