BY Mohammad Emam Prof. OB GYN Mansoura Faculty of Medicine Mansoura integrated fertility center MIFC EGYPT

1. BY Mohammad Emam Prof. OB& GYN Mansoura Faculty of Medicine Mansoura integrated fertility center (MIFC) EGYPT

2. Metabolic Syndrome ( MS) =Syndrome X =IR Is a cluster of metabolic disorders, with a subnormal biological response to insulin occurring mainly in visceral obesity.

3. Diagnostic Criteria for Metabolic Syndrome

4. Two of the following three features are present, after exclusion of other etiologies : (i) Oligomenorrhoea and or Anovulation (ii) Hyperandrogenism and/or hyperandrogenemia. (iii) Polycystic ovaries (sonar).

5. Phenotypes (Rotterdam) PCOS WITH PCO . PCO + HYPERANDROGENISM + ANOVULATION. PCO + Hyperandrogenism. PCO + Anovulation. PCOS WITHOUT PCO . Hyperandrogenism + Anovulation. PCO WITHOUT PCOS. ( Isolated PCO = Asymptomatic PCO ).

6. What is The significance of PCO in PCOS?? The presence of PCO usually correlates with the presence of insulin resistance (Richard J 2002).

7. Prevalence Of MS In PCOS MS is present in 2/3 of the PCOS (2-fold higher than women in the general population).

8. Pitfalls Rotterdam Definition doubts still exist regarding borderline groups of patients ,such as hirsute ovulatory Normoandrogenic women with PCO???. Neglect role of IR

9. PCOS + IR (70 % ). PCOS without IR (Legro etal 2004). Phenotypes Of PCOS According to IR

10. 1) IR Phenotype of PCOS  Abdominal obesity ( Minority may be lean) Acanthosis Nigericans. Hirsutism. Resistance to CC,

11. 2) PCOS Without IR Lean. Euinsulinemic/ Euglycemic Enhanced Ovarian Sensitivity to insulin (although no hyperinsulinemia).

12. RATIONALE MS Is associated with medical and psychosocial co-morbidities that are both immediate and long-term ( PCOS Is one of these co-morbidities ). PCOS: PCOS is now recognized as an important metabolic and reproductive disorder . So, Overlap and vicious circle can be present between PCOS and MS.

13. Co-morbidities With IR

14. Objective To illustrate the link between two current ,intimate and hidden epidemics , MS and PCOS . To pinpoint the role of gynecologists regarding the management of PCOS in the era of MS.

15. Link between MS & PCOS

16. The Central Player ( Insulin Resistance & Vicious circle )

17. The high ovarian response to insulin. Opposed by the whole body resistance. IR : The central paradox

18. Genetic Of (MS) & PCOS There is evidence for linkage of the hyperandrogenemia phenotype with an allele of a marker locus on chromosome 19, in the region of the gene encoding the insulin receptor.

20. How IR Can Be Confirmed ?? Fasting glucose / insulin < 4.5 Fasting insulin > 24 uU / ml One hour insulin post OGTT-75 gm > 150 uU/ml

21. Targets for ttt

22. Causative ttt Life- style modifications: Diet modification Weight loss Exercise Psychosocial support. Cessation smoking. Improve IR ( Metformin)

23. Proposed Approach for ttt of Anovulation In PCOS

24. The advantages of Metformin over drilling continue beyond conception: It reduces the miscarriage rate. Decreases the development of gestational diabetes.

25. Indications Of Drilling Regressed behind. Failure of : Change of life style. Insulin sensitizing agents. CC +/- HMG.

26. Role Of Metformin In None IR ( PCOS) Prevents starting vicious circle of hyperandrogenemia - IR . Improve spontaneous and CC-induced ovulation. Improve follicular maturation in IVF cycles. The continuation in the first trimester appears to reduce the risk of abortion ( Metformin = FDA group B ).

27. Conclusions We are facing two current intimate epidemics ( MS & PCOS ) which affect a large scale of population and also affect their reproductive future.

28. Gynecologists should categorize any case of PCOS ,depending on : Rotterdam criteria. IR or not Conclusions

29. conclusions Insulin sensitizers are the milestone in ttt of PCOS : whether as a causative therapy in ( IR) sub phenotype. OR AS A prohibitor of the starting Hyperandrogenemia- IR vicious circle in (none IR) sub phenotype