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Thursday, January 28, 2016

PCOS Infertility Has New Explanation

PCOS causes infertility. It was always assumed that failure to ovulate was the main cause of not getting pregnant in women with PCOS, and it is clear that this is still a cause. Beyond not ovulating it was thought that the irregular shedding of the lining, would perhaps produce loss of a fertilized egg. But that was not established firmly. And fertility studies published in the Cochrane based review showed that miscarriages are more frequent. Traditional treatment of infertility in women with PCOS has centered on treating the lack of consistent ovulation. New studies discussed in the American Journal of Obstetrics and Gynecology in their October 2015 issue  have now shown that treatment of the lining of the uterus to make it healthy before trying for pregnancy is very important. The treatment would be fairly strait forward treatment with progesterone for several cycles before trying for pregnancy. And now the American College of Obstetriians and gynecologists has stated that for women with both PCOS and obesity ( BMI greater than 30) there is a greater live birth rate in women with letrozole than clomid.
When the uterus is then ready you progress to treadment of ovulation if still necessary through the more traditional therapies.
Initiation Clomid) and letrozole (the aromatase inhibitor, breast cancer treatment Femara) are both effective fertility treatment due to the stimulation of ovulation. This may be given to women who have menstrual cycles and have not yet conceived, or women who have no menstrual periods, even for those who have PCOS. About 60 to 75% of women who are infertile due to no menstrual periods will ovulate when given these relatively low cost medications. They both work by signaling there is low estrogen and thus more hormones are released to increase the number of eggs ovulated. Clomid is a SERM. Selective Estrogen Receptor Modulators (SERMs) could bind to the estrogen receptor to stimulate estrogen properties or to counter them. For fertility we make use of the fact that Clomid medication binds to the surface of cells the pituitary gland and thus pushes the hormonal factors to produce more growth of the follicle that will eventually produce a fertile egg. Because it is so safe and effective many physicians will use it very early on for infertility treatment, in the low dosage, for 1-6 cycles. Letrozole is an aromatase inhibitor, essentially blocking the production of estrogen and making estrogen levels transiently very low . It may be better than Clomid based on some recent studies at the University of Nottingham in Derby, England. Dr. Saad Amer who headed these studies also believed there were fewer fetal anomalies with letrozole than with clomifene, however the rates of birth defects were only slightly higher than the rates of birth defects in women who did not use these medications. When women take these medications potential side effects, other than the side effects of the medication administration, include twining, preterm birth, miscarriage, or tubal pregnancy. Some physicians use very close monitoring of the medications, but others merely recommend timing of sex with ovulation after taking an ovulation medicine. Patients should also discuss with their gyno the fact that Clomid is indicated for infertility treatment, and letrozole for this indication is considered off label.

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