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The majority of women with anovulation or oligoovulation due to polycystic ovary syndrome (PCOS) often have clinical and/or biochemical evidence of hyperandrogenism. This chapter describes the treatment with clomiphene citrate (CC), aromatase inhibitors (AIs), gonadotropins, and metformin followed by a discussion on the management of women with PCOS undergoing in vitro fertilization (IVF). It deals with the combined treatment of clomiphene with metformin. In women with PCOS, metformin is said to lower fasting insulin concentrations but also probably acts directly on theca cells and attenuates androgen production. The aim of the chronic low-dose step-up protocol is to obtain the ovulation of a single follicle. While results of IVF for women with PCOS are generally satisfactory compared with those with normal ovaries, ovarian stimulation protocols must be adapted accordingly to avoid the major pitfall of ovarian hyperstimulation syndrome (OHSS) in these women.
Female fertility begins to decline many years before menopause, despite continued regular ovulatory cycles. Decreased fecundity with increasing female age has long been recognized in demographic and epidemiological studies. Traditionally, the evaluation of the infertile female consists of: (i) ovulation assessment (ovulatory factors), (ii) evaluation of the uterine morphology (ovulation assessment) and tubal patency (tubal factors), (iii) assessment of the presence of pelvic pathology (by laparoscopy) (peritoneal factors), and (iv) postcoital test (cervical factors). Hysterosalpingography (HSG), laparoscopy are widely used in assessing infertility. Chlamydia antibody testing is a screening method for assessing tubal infertility. HSG, sonohysterography, hystero-salpingo contrast sonography (HyCoSy), magnetic resonance imaging (MRI) and hysteroscopy are used in assessment of uterine factors related to infertility. Currently, the best method to monitor ovulation is transvaginal ultrasound, which can be used to demonstrate the growth of a dominant follicle and provide presumptive evidence of ovulation and leutinization.
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