Reproductive Endocrine Assoc. Assisted Reproduction Q & A

What is Polycystic Ovarian Syndrome?

Polycystic Ovarian Syndrome (PCOS, or Stein - Leventhal Syndrome) is a disorder characterized by anovulation, hirsutism and obesity. There is an increased sensitivity of the ovaries to gonadotropins, an increase in androgin levels and a propensity to develop ovarian microcysts.

DIAGNOSIS OF PCOD
  • Disordered or absent menstrual cycles and failure of ovulation
  • High levels of plasma androstenedione and testosterone or free testosterone
  • High plasma LH:FHS ratios or >3:1
  • Higher levels of bioactive LH
  • Masculinization of facial and pubic hair and body characteristics
  • Obesity in some patients
  • Many small follicles on ultrasound or in ovarian biopsies
  • Obese and hirute patients may have exaggerated insulin responses in oral glucose tolerance tests

Various therapies are available for hyperandrogenic syndromes. Ovarian wedge resection is the classic method for treating PCOD. It is surprisingly effective and even enjoying a resurgence today. The reduction in ovarian mass can have dramatic effects, with a decrement in ovarian androgen secretion interrupting the vicious cycle that results in exaggerated LH and reduced FSH release. Later laparoscopic wedge resection involves creating multiple pockets 1 cm deep throughout the surface of the ovary, to destroy a significant amount of ovarian cortex and stroma. All surgical methods are contraindicated in patients desiring pregnancy, because of the risks of producing potentially severe periovarian adhesions.

Medical methods involving dexamethasone or other compounds, and especially LH-RHa are effective with many forms of the syndrome. Dexamethasone will suppress the adrenal glands and reduce the output of estradiol but not of progesterone by granulosa cells.

LH-RHa effectively suppresses ovarian perandrogenism. Androgen levels decline rapidly to those typical women after oophonectomy. Gonadotrophs are desensitized and LH and estradiol levels decline for up to 550 days. Care is essential in inducing ovulation in PCOD patients. When used to induce ovulation, LH-RHa can induce explosive responses in PCOD patients with elevated LH and normal FSH and increase LH pulse frequency without a nocturnal slowdown. Their LH:FSH ratios increase enormously as pituitary sensitivity to LH-RH is enhanced.

PCOD patients may be given LH-RHa before FSH or hMG for ovarian stimulation. Responses are better than with FSH or hMG alone. Many follicles can develop posing the threat of ovarian hyperstimulation syndrome. Clomiphene triggers follicle growth in some patients but others will have clomiphene resistance.

Principles & Practice of Assisted Human Reproduction
Robert G Edwards, PhD & Steven A Brody M.D.
W.B. Sanders

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