PCOS is a hormonal condition affecting 1 in 10 women of reproductive age. The exact cause of this condition is unknown but its accepted that it is a combination of genetic and environmental factors. Unbalanced hormone levels are also key factors why PCOS leads to fertility issues. In this webinar, Dr Marina Soto Sogorb, Gynaecologist and Obstetrician at Phi Fertility, talks about polycystic ovary syndrome and answers the important question: Can IVF help to overcome infertility caused by PCOS?
According to Dr Marina Soto Sogorb, in order to understand polycystic ovary syndrome (PCOS) one has to understand what’s going on in a normal menstrual cycle. Brain structures called the hypothalamus and pituitary gland control the menstrual cycle. Together with the ovaries and the uterus, they follow a sequence every month. The objective of this sequence is to prepare the body for pregnancy. Hypothalamus produces FSH (follicle-stimulating hormone) and LH (luteinizing hormone) while the ovaries produce oestrogen and progesterone. These hormones make the lining of the uterus thicker to prepare the body for pregnancy. During the first half of the menstrual cycle, FSH increases. This increase stimulates the ovaries to produce the cord of follicles, among which one stands out of the rest. This is the so-called ‘dominant follicle’. It produces A rising level of oestrogen and this, in turn, causes the thickening of the endometrium (the lining of the uterus). The increase of oestrogen also causes the release of LH in the pituitary gland. At the moment of LH peak, the ovulation occurs.
Ovulation is the release of an egg from the ovarian follicle. After ovulation, the next phase of the cycle begins. The follicle, that was left by an egg, starts to produce progesterone. When fertilisation doesn’t take place, the follicle contracts inside the ovary and the levels of oestrogen and progesterone begin to shrink. This causes the endometrium to shed and results in menstruation – and the start of the next menstrual cycle.
After this detailed explanation of the menstrual cycle, Dr Marina Soto Sogorb goes on to talk about PCOS ( polycystic ovary syndrome) itself. PCOS is the most common endocrinopathy in women of reproductive age. Its prevalence oscillates among 10%. The causes of PCOS are generally unknown – however, genetic and environmental factors are taken into account.
PCOS syndrome and its symptoms
PCOS is characterised by hormonal imbalance. What we understand by that is a higher production of LH (in comparison with FSH) and an increase in androgens. Hormonal imbalance causes ovulatory disfunction, resulting in excessive follicular recruitment: large cohorts of follicles and growth of follicles ceases.
The changes in hormone levels influence women’s health, well-being and physical appearance. One of the symptoms is hyperandrogenism which manifests itself as acne, increased body hair, scalp hair loss, as well as weight grow. Ovulatory dysfunction on the other hand, results in an absence of, or irregular menstrual periods and difficulty in getting pregnant. Dr Marina Soto Sogorb admits that the symptoms can be very variable but in many cases the first symptom is infertility.
Dr Marina Soto Sogorb says that women often ask how they can know if they have PCOS. In order to diagnose PCOS, a gynaecologist should conduct an interview to determine a patient’s medical history. An ultrasound scan of ovaries is also needed. The ultrasound description of a polycystic ovary consists of more than 12 follicles with the diameter of 2-9 millimetres. A gynaecologist may request a hormonal determination, too. When the latter shows an increase in LH levels and androgens, it is a sign of PCOS.
However, due to phenotypic heterogeneity, the diagnosis of PCOS is very complex. Medical criteria used by doctors for diagnosis are : hyperandrogenism, ovulatory dysfunction (absent or irregular periods) and polycystic ovaries on ultrasound. At least 2 of these 3 criteria have to be met in order to recognise PCOS in a woman. Dr Marina Soto Sogorb says that according to these criteria, we can observe 4 phenotypes: A,B,C and D. The most common is ‘A’ and it arises from the combination of hyperandrogenism, ovulary dysfunction and polycystic ovaries morphology by ultrasound. About 60% of women with PCOS are classified with phenotype ‘A’. The phenotype ‘B’ is a combination of hyperandrogenismand ovulary dysfunction while ‘C’ (called an ‘ovulatory phenotype’) conflates hyperandrogenism and polycystic ovaries morphology. The last phenotype ‘D’, which is also the least common one, combines both ovulary dysfunction and ultrasound criteria.
Treatment options – PCOS
Dr Marina Soto Sogorb says that there are few options for PCOS treatment. If the problem is weight related then one of the most effective approaches is weight loss. Manifestations of hyperandrogenism may be treated with contraceptive pills – assuming, of course, that a patient is not planning a pregnancy. Another option here are antiandrogens – a group of medicines that counteract the effects of the male sex hormones.
Combating PCOS and infertility
What is the solution for infertility problems resulting from PCOS? According to Dr Marina Soto Sogorb, the main problem here is anovulation – the failure of ovaries to release an oocyte during a menstrual cycle. Assuming that the only pathological factor is the lack of ovulation, then doctors usually recommend an available reproduction technique as a cure.
The first step of the treatment is clomiphene citrate. It’s an ovulation inductor administered orally that stimulates the ovaries to realise follicles. It’s an easy and economic way of treatment. The results are quite impressive – the ovulation rate is 80% while cumulative gestation rate equals 40% (in 6 cycles). However, the main risk here is multifollicular development and, as a result, a multiple pregnancy.
If a woman doesn’t get pregnant with clomiphene citrate, artificial insemination is the second step. It consists of ovarian stimulation with low doses of gonadotropins (either FSH or LH) in subcutaneous injections. After the ovulation occurs, the semen (collected on the day of the insemination) is introduced into the uterine cavity. Dr Marina Soto Sogorb assures that insemination isn’t a painful procedure and it doesn’t need anaesthesia. Again, like in case of clomiphene citrate, the main risk is multifollicular development and a multiple pregnancy. The gestation rate here is 15% in one cycle while cumulative pregnancy rate is 30%.
PCOS and IVF
If a woman does not get pregnant by artificial insemination, IVF is the next step. It is the most expensive and also the most complex technique as it consists of several phases. The first one is ovarian stimulation with high doses of gonadotropins to achieve the development of multiple follicles. When the follicles achieve an adequate size, the ovarian puncture for oocyte extraction takes place. The puncture is performed in an operating room under general anaesthesia. Then the fertilisation of the egg is conducted in a laboratory. Embryonic laboratory development takes about 2-6 days and then the embryo transfer is made. The gestation rate in PCOS patients after IVF is up to 75%. Having said that, Dr Marina Soto Sogorb admits that IVF is a real solution to infertility caused by polycystic ovary syndrome.