Cinnah Cad. No:54 Çankaya Ankara Türkiye


What are the Treatment Options in patients with PCOS?
Polycystic ovarian syndrome (PCOS) is the most common endocrinological disorder in reproductive age period. The frequency of PCOS is around 15-17%. PCOS is characterized by menstrual irregularity characterized by i) less than 9 menses per year, ii) androgen excess-either increased serum androgen (male hormone) levels or skin findings of increased androgen levels characterized by hirsutismus (increased hair growth), oily skin, acne and hair loss and iii) polycystic ovarian appearance at ultrasonography (more than 12 antral follicles of 2-9 mm in each ovary).
The frequency of being overweight and obesity is increased in women suffering from PCOS.  Furthermore, excess fat is deposited on the low abdominal region (male-type obesity) in such cases.
Insulin resistance is characteristic in patients affected by PCOS.  Therefore, impaired glucose tolerance as well as type-2 diabetes are increased in women with PCOS.  Most probably, the risk of hypertension and coronary heart disease may also be increased in such women.  Therefore, one should keep in mind that PCOS is a metabolic disorder, associated with long-term risk factors including type-2 diabetes, hypertension and coronary heart disease.
Since the majority of these patients do not ovulate on themselves, there is no progesterone (ovulation hormone) production.  Since progesterone opposes estrogen action on the inner lining of uterus and with the lack of progesterone in PCOS patients with long-lasting ignored cases, the thickness of the inner lining might be increased.  In such cases, even the risk of cancer of the inner lining might be increased.  Therefore, it is essential that these patients should have medications to have regular cycles. 
PCOS is the most common reason for infertility due to the absence of ovulation.  When fertility is desired in such women, medications are used to induce ovulation.  Treatment options in patients having difficulty in getting pregnancy are;
  • The first-line treatment is a drug, which contains clomiphene citrate (Klomen, Gonaphene or Serophene). It is an oral medication, easy to use and cheap. There is no need for follow-up with ultrasonography during this treatment. This drug is started as 50 mg (1 tablet) per day; based on the ovarian response the dose might be increased, if necessary.  With this treatment in 6 months, 80% of the patients ovulate and 40% conceive. 
  • The second-line treatment is low-dose daily injection therapy. In order to stimulate ovulation, by using daily rather small doses of gonadotrophins (Gonal F, Puregon, Menogon, Menopur, Fostimon or Merional),  1 or 2 follicles are aimed to be grown. Final shut injection is performed when the size of follicle(s) reaches 17-18 mm.  With this approach, ovulation is induced in 95% of the patients.  The pregnancy rate per treatment cycle is around 20-23%.  Although not mandatory, we also perform intrauterine insemination (IUI-putting the washed sperm into the uterus 40 hours after the final shot by a catheter under ultrasonographic guidance).  Following 3-4 cycles of such treatment, if the patient fails to conceive, IVF treatment is recommended.
  • The third-line treatment is IVF.  Pregnancy rates achieved with IVF in such patients are very reassuring at least as good as compared to those patients not suffering PCOS.  Since the number of oocytes harvested is very good in patients, the majority of such patients have surplus blastocysts to be frozen.  Such an approach obviously augments cumulative (fresh+frozen) pregnancy rates.