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Folic acid should be taken at a daily dose of 400 mcg or, in those who are obese, 5 mg. There is debate about the restriction of fertility treatment to women who are overweight, although there is no doubt that obesity has a significant adverse impact on reproductive outcome. It influences not only the chance of conception but also the response to fertility treatment and increases the risk of miscarriage, congenital anomalies and pregnancy complications . The British Fertility Society guidance suggests that treatment should be deferred until the BMI is less than 35 kg/m2, although in those with more time (e.g. less than 37 years, normal ovarian reserve) a weight reduction to a BMI of less than 30 kg/m2 is preferable . Even a moderate weight loss of 5–10% of body weight can be sufficient to restore fertility and improve metabolic parameters.
Conventional ovulation induction (OI) treatments are highly effective in achieving pregnancy when anovulation is the only factor in a couple’s conception delay. Fertility declines with female age and lifestyle factors including smoking, alcohol intake and body weight negatively influence the success of treatment. Careful planning and monitoring of treatment is necessary to avoid complications such as multiple pregnancy and ovarian hyperstimulation syndrome (OHSS).
Pediatric and adolescent gynecology (PAG) is recognized as a specialist area and clinicians working in PAG need specific expertise. A wide spectrum of conditions needs to be addressed, ranging from simple disorders which respond to basic treatment to complex congenital anomalies with a genetic origin and life-long health consequences. Investigations must be appropriate and treatment should reduce symptoms and distress whilst optimizing gynecological and reproductive potential. Centered upon a series of common clinical presentations, this book includes stepwise guidance on the initial investigations, management, and treatment options. Guidance is supported by the most up-to-date evidence-base, written by clinicians with dedicated clinical and research experience in PAG. New techniques - such as laparoscopic surgery - are included and the importance of the psychological assessment of children with specific PAG disorders is highlighted. The book also includes an authoritative chapter on safeguarding - recognizing the unique opportunity for gynecologists in child protection.
This chapter examines the evidence for ethnic variation in the polycystic ovary syndrome (PCOS) phenotype and explores the possible basis of this phenomenon. Evaluating ethnic variations in the expression of PCOS requires systematic review of the strength of the evidence, preferably from population-based data or from large samples in the clinic setting. The chapter evaluates reports of differing expression of hyperandrogenism, obesity, insulin resistance and metabolic manifestations. The reports discussed mainly comprise comparative and case-control studies providing level III evidence. The available data show variations in the PCOS phenotype among Caribbean Hispanic, Mexican American, Japanese, indigenous Chinese/Taiwanese, migrant versus indigenous South Asian, Thai, Malay, southern European, indigenous Canadian and migrant Arab women. Reports on the degree of hyperandrogenism in PCOS in women from different regions of the world are varied, as they are based on various diagnostic criteria, clinical settings, age and ethnic origins.
Polycystic ovary syndrome (PCOS) is the most common endocrine disturbance, affecting 10-15% of women in the UK. The definition of PCOS has been much debated, while its pathophysiology appears to be multifactorial and is still being actively researched. There is no doubt that PCOS has a significant effect on quality of life and psychological morbidity and, as many specialists are involved in its management, a multidisciplinary approach is required. The 59th RCOG Study Group brought together a range of experts who treat women with PCOS. This book presents the findings of the Study Group, including:A definition of PCOSThe accuracy of diagnostic interventionsThe particular challenges of adolescent diagnosis and managementThe correlation to ethnicityCurrent approaches to therapyThe potential individualisation of therapy The role of the alternative therapies used to manage some aspects of PCOS.
Polycystic ovary syndrome (PCOS) is a syndrome with varied manifestations both within different populations and between different populations. With recent increases in the understanding of the pathophysiology of PCOS and the recognition of the importance of ultrasound in defining the morphology of the polycystic ovary, the syndrome has now been defined as the presence of two of the following three criteria: oligo-ovulation and/or anovulation, hyperandrogenism (clinical and/or biochemical), polycystic ovaries; with the exclusion of other aetiologies of menstrual disturbance and androgen excess. There are likely to be many routes to the development of PCOS, including genetic predisposition, environmental factors and disturbances of a number of endocrine pathways. To establish the diagnosis of PCOS it is important to exclude other disorders with a similar clinical presentation, such as congenital adrenal hyperplasia, Cushing syndrome, and androgen-secreting tumours.
The surgical management of anovulatory infertility in polycystic ovary syndrome (PCOS) has traditionally involved the use of clomifene citrate and then gonadotrophin therapy or laparoscopic ovarian surgery in those who are clomifene-resistant. Laparoscopic ovarian surgery is a useful therapy for anovulatory women with PCOS who need a laparoscopic assessment of their pelvis or who live too far away from the hospital to be able to attend for the intensive monitoring required for gonadotrophin therapy. Commonly employed methods for laparoscopic surgery include monopolar electrocautery (diathermy) and laser. The risk of periovarian adhesion formation can be reduced by abdominal lavage and early second-look laparoscopy, with adhesiolysis if necessary. The chance of achieving a continuing pregnancy within 6 months is less than with carefully conducted ovulation induction with gonadotrophins but, if adjuvant ovulation induction agents are used in those who do not initially respond, the 12-month pregnancy rates are similar.
The diagnosis of hyperandrogenism is dependent on the accuracy and precision of measurement of the clinical features and the laboratory androgen assays. Hyperandrogenism in the context of polycystic ovary syndrome (PCOS) is a term used loosely to encompass both the clinical features of acne, hirsuties and androgenic alopecia and the laboratory evidence of hyperandrogenaemia. The relationship between acne and biochemical hyperandrogenaemia is well established but the number of women with acne in unselected populations is so great that it makes the link with PCOS unconvincing, particularly since the incidence of acne seems to be greater than that of PCOS. Anovulation is assessed by measuring the serum progesterone during the mid-luteal phase. Consecutive series of women with either a single symptom or various combinations of symptoms would be subjected to formal receiver operating characteristic (ROC) analysis to determine the optimal diagnostic characteristics.