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Polycystic ovary syndrome (PCOS) is a notoriously heterogeneous, common reproductive disorder associated with many coexisting conditions, including hyperandrogenemia, obesity, insulin resistance and other signs of metabolic dysfunction. PCOS is often diagnosed in the context of anovulatory infertility. However, more recent research disclosed an association of PCOS with increased chances for pregnancy complications, adverse perinatal outcomes and suboptimal long-term health of children born to women with PCOS. This chapter provides an overview of current literature concerning obstetrical complications in women with PCOS, especially increased risk for gestational diabetes (OR 2.7–2.9), hypertensive disorders of pregnancy (including preeclampsia, OR 1.9–4.2) and preterm birth (OR 1.5–2.2). In addition, information regarding children’s outcomes is provided, including birth weight, cardiovascular health and neurodevelopmental health. Finally, pathological pathways including biomarker data in pregnancy and placenta morphology are discussed.
Polycystic ovary syndrome (PCOS) is one of the most common reproductive health problems of women, causing irregular periods and potential infertility amongst other challenging symptoms. Effective treatment remains a significant challenge and is largely achieved through hormonal medication and lifestyle changes. This third edition covers the aetiology, pathology, impact on fertility and effective medical and surgical management. The content has been thoroughly revised in line with updated guidelines and research developments in the field. A new chapter on the patient's perspective has been included, bringing valuable insight into the lived experience of the condition. Mood disorders and the psychological aspects of PCOS are also covered for the first time. This is a key reference for all clinicians involved in the care of patients with PCOS, including gynaecologists, IVF specialists and reproductive endocrinologists.
The lack of ovulatory cycles may be considered as a major problem for women seeking pregnancy. This is reflected by the fact that about 20 percent of couples visiting a fertility clinic with an unfulfilled wish to conceive present with anovulation [1]. Clinical manifestation of anovulation is oligomenorrhea (intermenstrual period > 35 days) or amenorrhea (intermenstrual period > 6 months). Although ovulation may occur in oligomenorrhea, the longer the time period between menstruations the smaller the chance of that cycle being ovulatory. Classification of anovulatory patients may be performed using the criteria of the World Health Organization (WHO) as determined by Rowe et al.
Clinical manifestation of anovulation is oligomenorrhea or amenorrhea. Patients with hyperandrogenemia and polycystic ovaries (without ovulation disorders) and patients with polycystic ovaries and ovulation disorders (without hyperandrogenism) may now be included in polycystic ovary syndrome (PCOS) diagnosis. The majority of anovulatory patients (about 80%) will have normal serum concentrations of estradiol (E2) and follicle-stimulating hormone (FSH) and a small proportion (approximately 10%) decreased concentrations of both hormones. Traditionally, ovulation induction treatment in normogonadotropic anovulation is started with an antiestrogen (CC) and, in case of treatment failure or absence of conception, this is followed by exogenous FSH. The most serious complications resulting from ovulation induction are caused by the limited control of follicular development. Increased availability of genetic profiles will be helpful to accomplish a more patient-tailored approach by identification of beneficial subgroups for certain interventions.
Achieving a distinct ovarian response usually represents the desired outcome of pharmacological interventions on the hypothalamic-pituitary-ovarian axis in ovulation induction and ovarian stimulation. The considerable individual variability in ovarian response to stimulation, however, necessitates close monitoring and dose adjustment for each woman. Combining prediction models for success in ovulation induction and success in conception would allow prediction of the likelihood of conception before anti-estrogen therapy is initiated, allowing women with a low percentage chance of a live birth to be directed towards another first-line treatment modality. Gonadotrophins are commonly used as a second-line treatment to restore ovarian function in women with WHO group II anovulation who have not responded to anti-estrogen therapy. Despite problems in using the current predictive tests in clinical practice, the wide variation in patients' characteristics mean that individualised patient-tailored approaches remain mandatory for safe and effective ovarian stimulation.
Efforts to improve treatment outcome of ovulation induction are increasingly focused on patient characteristics instead of treatment characteristics. Fertility treatment for hypogonadotropic anovulation may consist of a pulsatile gonadotropin-releasing hormone (GnRH) pump or direct stimulation of the ovaries with exogenous gonadotropins (FSH and LH). Although the classical treatment sequence for normogonadotropic anovulation (WHO2) is clomiphene citrate followed by FSH, a number of new interventions are proven to be useful for these patients. Patients presenting with oligo- or amenorrhea due to hyperprolactinemia may be effectively treated with dopamine agonists. Antiestrogens are first-line treatment options in normogonadotropic anovulation. The major complication of ovulation induction is development of multiple follicles resulting in increased chances of multiple pregnancy and ovarian hyperstimulation syndrome (OHSS). New compounds or strategies such as insulin sensitizers, aromatase inhibitors, and laparoscopic ovarian electrocautery (LEO) should be compared to traditional compounds in patient subgroups with various characteristics.
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