PCOS and Fertility Positive Steps Forward

1. PCOS and FertilityPositive Steps Forward Dr Michelle Wellman MBBS FRANZCOG

2. Questions • • What is Polycystic Ovary Syndrome (PCOS)? • • Why is PCOS important? • • What causes PCOS? • Can PCOS be cured? • Will I be able to have children?

3. What is PCOS? • Involves more than just the ovaries • Syndrome = Group of Symptoms or signs • 2 out of 3

4. PCOS Types Menstrual Irregularities PCOS PCOS PCOS Androgens Ultrasound PCOS

5. Irregular periods • Cycles consistently more than 35 days • Less than 10 periods per year

6. Hypothalamus GnRH Pituitary FSH LH Ovaries Oestrogen Progesterone Uterus

7. Ovulation PCOS No ovulation Infrequent ovulation Progesterone

8. Increased androgens • Androgens • = ‘male-type’ hormone • Sometimes increased hair growth on face, chest, back (hirsutism) • Sometimes loss of hair on the scalp (alopecia) • Sometimes acne • Can be seen on a blood test

9. Ultrasound appearance • Transvaginal (internal)ultrasound is best

10. What is not PCOS? • Single cysts on ultrasound or follicles • Loss of periods due to stress, rapid weight • loss or excessive exercise • Loss of periods due to premature menopause

11. Why is PCOS important? • Common • - Estimated to affect between 12 and 21% of the population • - Up to 70% remains undiagnosed • Long and short term consequences

12. Short term Long term • Irregular periods • Hair growth • Acne • Infertility • Psychological • Type 2 Diabetes • Increased risk of cardiovascular disease eg. strokes, heart attacks

13. Weight and PCOS • Not all women with PCOS are overweight • Being overweight increases the signs and symptoms of PCOS • Weight loss has been shown to reduce the signs and symptoms of PCOS and reduce the risk of long-term consequences

14. If you think you may have PCOS • Speak with your GP • They may organise appropriate tests if required • May require input from other specialists • Gynaecologist • Fertility Specialist • Endocrinologist • Dermatologist • May refer to other allied health professionals • Dietician

15. What causes PCOS? LIFESTYLE GENETICS Hormonal Changes ↑ Androgens ↑ Insulin OVARIES Anovulation Irregular Periods CARDIO- VASCULAR RISK Hair Growth Acne

16. Can PCOS be cured? • No cure • but very effective treatment options for managing the associated problems • Removing the ‘cysts’ does not cure the problem • LIFESTYLE CHANGE • first line treatment for all PCOS problems

17. SMALL CHANGES MAKE A BIG DIFFERENCE

18. Menstrual problems • Medication - pill, cyclical progesterone • Mirena® - intrauterine contraceptive device • Surgery

19. Hair growth • Cosmetic treatment eg laser, electrolysis • Medication eg. pill, anti-androgenic

20. WILL I BE ABLE TO HAVE CHILDREN?

21. Anovulation • = ovary does not release an egg • In most instances ovulation can be restored with simple, inexpensive techniques

22. WEIGHT LOSS • If overweight even small (5-10%) reduction in bodyweight can reduce insulin resistance and restore ovulation • Other health benefits • Benefits during pregnancy • - reduces miscarriage rate • - reduces diabetes during pregnancy

23. WEIGHT LOSS SURGERY • Laparoscopic banding, gastric sleeve operations • Can be useful for very overweight woman who are unable to lose weight after prolonged efforts at lifestyle change • General recommendation to defer conception for 12 months or until weight-loss stabilised

24. Clomiphene Citrate • Trade names Serophene® and Clomid® • Generally low risk and low cost • Twins 5-7%, Triplets 0.3% • Response rate 60-85% • Pregnancy rate 50% after 6 ovulatory cycles

25. Clomiphene tracking Allows assessment of response, intercourse timing and triggering Day 5 start clomiphene Day 9 stop clomiphene Day 1 Day 11-13 scan Day 21 Progesterone If no response increase dose Progesterone 10 days or blood test Period Ovulation + intercourse +/- trigger

26. Metformin • Medication used to reduce blood glucose levels in diabetes • Taken 3-4 times a day • May be useful for women who do not respond to maximum doses of clomiphene • Sometimes beneficial on its own to induce ovulation in women with lower BMI

27. Gonadotropins • Use synthetic FSH to stimulate ovulation (GonalF® or Puregon®) • Usually used for women who do not respond to Clomiphene • Rare not to respond • Additional trigger (ovulation) injection and luteal (lining)support medication usually required

28. Puregon® Gonal F®

29. FSH Ovulation Induction Protocol Increase dose slowly - can be very sensitive hCG 5000u Starting dose Scan d7 Scan d14 Scan d21 Follicle =16mm Increase dose by 50% Increase dose by 50% 25-50iu/day

30. Laparoscopic Ovarian Drilling (LOD) • Day surgery procedure via keyhole surgery • Can restore ovulation in 60-80% of women in the short term (few months) • Lower risk of multiple pregnancy

31. IVF • Generally last option • Increased sensitivity to medication in patients with PCOS • If other associated factors may be indicated, but not always necessary i.e semen abnormality

32. If IVF is needed FertilitySA has outstanding pregnancy rates!

33. Resources • Jean Hailes Foundation Website • www.jeanhailes.org.au • FertilitySA website • www.fertilitysa.com.au • Polycystic Ovary Syndrome Association of Australia (POSAA) • www.main.posaa.asn.au • Brochures

34. Any Questions?

35. Consulting Clinic 345 Carrington Street Adelaide SA 5000 Phone 8100 2900 e info@fertilitysa.com.au w www.fertilitysa.com.au