Use of LHRH agonists in the treatment of anovulation in women with polycystic ovary syndrome

[Which ovarian stimulation to which women: The polycystic ovary syndrome (PCOS)]

Polycystic ovarian syndrome (PCOS) is a frequent pathology in the young woman, linking infertility to a metabolic disease. Initial support will include a plan (in the case of overweight or obesity) to lose at least 5 to 10% of the weight. Subsequently, clomiphene citrate is the first treatment for ovulation induction with pregnancy rates of 40 to 80% after 6 cycles. If there is resistance to clomiphene citrate, the choice will be between the ovarian drilling (50-60% of pregnancy in the year following, including the half spontaneous) or ovarian stimulation with gonadotropins. The risk of ovarian stimulation in these women is hyperstimulation and multiple pregnancies. We also discuss the place of the GnRH pulsatile administration, insulin-sensitizers, in vitro fertilization and in vitro maturation in these women. Once infertility support, these women should be long-term followed because of the neoplasic and cardiovascular risks they present.

Evaluation of ovarian function and metabolic factors in women affected by polycystic ovary syndrome after treatment with D-Chiro-Inositol

PURPOSE

To evaluate the effects of D-Chiro-Inositol in women affected by polycystic ovary syndrome (PCOS).

METHODS

We enrolled 48 patients, with homogeneous bio-physical characteristics, affected by PCOS and menstrual irregularities. These patients underwent treatment with 1 gr of D-Chiro-Inositol/die plus 400 mcg of Folic Acid/die orally for 6 months. We analyzed pre-treatment and post-treatment BMI, Systolic and Diastolic blood pressure, Ferriman-Gallwey score, Cremoncini score, serum LH, LH/FSH ratio, total and free testosterone, DHEA-S, Δ-4-androstenedione, SHBG, prolactin, glucose/IRI ratio, HOMA index, and resumption of regular menstrual cycles.

RESULTS

We evidenced a statistically significant reduction of systolic blood pressure, Ferriman-Gallwey score, LH, LH/FSH ratio, total Testosterone, free Testosterone, ∆-4-Androstenedione, Prolactin, and HOMA Index; in the same patients, we noticed a statistically significant increase of SHBG and Glycemia/IRI ratio. Moreover, we observed statistically significant (62.5%; p < 0.05) post-treatment menstrual cycle regularization.

CONCLUSIONS

D-Chiro-Inositol is effective in improving ovarian function and metabolism of patients affected by PCOS.

Common problems in induction of ovulation

There are many groups of women with anovulatory infertility who respond abnormally to conventional treatment. It is important to diagnose the underlying disorder correctly before commencing treatment. In this chapter we have discussed the various treatment modalities available and how they may be adapted to fit the particular clinical needs. In women who are profoundly hypo-oestrogenic, the 'priming' of the ovary using prolonged low-dose gonadotrophins offers a possible solution if both subcutaneous and intravenous pulsatile GnRH therapy has failed. It may also reduce the incidence of multiple pregnancies in these women. Growth hormone seems to augment the response to gonadotrophin in these women and may prove a useful adjunct to therapy once further experience of its use has been reported. Women with PCO have been a difficult group to treat because of their tendency to hyperstimulate. The low-dose gonadotrophin regimen outlined in this chapter overcomes the majority of these problems without reducing the rate of conception. This group continue to have an increased incidence of miscarriage. The introduction of combined therapy of hMG with a GnRH analogue may improve this situation, but the data from randomized controlled studies are still awaited. Ovarian failure remains an untreatable cause of infertility. A few women may become pregnant spontaneously, but these are the exception rather than the rule. Hormone replacement therapy should be offered to all these women because of the long-term problems of osteoporosis and cardiovascular disease. Products containing a low dose of oestrogen (e.g. Premarin 0.625 mg) will not interfere with ovulation if there should be a spontaneous resumption of ovarian activity.

Buserelin. A review of its pharmacodynamic and pharmacokinetic properties, and clinical profile

The gonadotrophin releasing hormone (GnRH) [luteinising hormone-releasing hormone (LHRH); gonadorelin] agonist buserelin is a promising new agent in the treatment of a variety of disorders in gynaecology and andrology, paediatrics and oncology. While a single dose of buserelin stimulates the release of pituitary gonadotrophins, multiple doses produce reversible pituitary desensitisation, and this specific blockade of gonadotrophin support to the gonads provides the basis for the drug's efficacy in conditions dependent on sex hormone secretion. Thus, buserelin provides comparable efficacy to orchidectomy or high dose estrogens in the treatment of hormone-sensitive prostate cancer and exhibits a lower incidence of adverse effects. During the early phase of treatment it may be particularly useful in combination with antiandrogens. Buserelin also appears promising in hormone-sensitive premenopausal breast cancer. Extensive studies have proven the value of buserelin in endometriosis, where it produces a transient remission with gradual recurrence of the disease on cessation of treatment. Surgical intervention is necessary in severe disease after buserelin-induced involution of the lesions. In patients with uterine leiomyoma, preliminary data suggest that buserelin may be beneficial in rendering surgery more conservative by reducing fibroid size, although it appears unlikely to preclude surgical intervention. The use of buserelin to induce a state of reversible hypogonadotrophism before administration of exogenous gonadotrophins is a promising strategy in the treatment of infertility associated with polycystic ovary syndrome and other conditions of infertility with underlying ovarian dysfunction; such a strategy also clearly enhances the efficiency of in vitro fertilisation programmes. Initial studies suggest its potential usefulness as a female contraceptive when administered intermittently in conjunction with a progestogen. Buserelin represents a first-line treatment of central precocious puberty. In endometriosis the adverse effect profile of buserelin is generally favourable, with hypoestrogenic effects such as hot flushes and vaginal dryness, and decreased libido, predominating. There is no apparent detrimental effect on lipid metabolism. The potential for adverse hypoestrogenic effects on bone mineral content with long term administration remains to be clarified. Thus, the GnRH agonist buserelin represents an advance in the treatment of a variety of gynaecological and andrological as well as paediatric and oncological conditions, infertility and other sex-hormone dependent conditions, with a low incidence of adverse treatment effects.

Laparoscopic treatment of polycystic ovarian syndrome

Laparoscopic techniques show a number of advantages in comparison with the classic ovarian wedge resection for the treatment of PCOD. An equally high ovulation rate is achieved with less trauma, and fewer postoperative adhesions result in a higher pregnancy rate. The procedure may be done on an outpatient basis with reduced operative and recovery time. No clear advantages have so far been shown to exist for any of the available techniques, i.e. laparoscopic biopsy, electrocautery, and the four laser systems (CO2, Nd-YAG, argon, KTP). It appears, however, that the laser techniques will be the methods of choice for the future. They combine optimal precision of operation handling with maximal safety and excellent bleeding control. With laparoscopic biopsy traumatic bleedings may occur, which can occasionally be difficult to control. With electrocautery, burns due to the uncontrolled effect of electric current have been described. Optimal application of the laser techniques requires extensive personnel training and experience. The laser equipment requires considerable capital expenditure of the order of 20,000-70,000 pounds. The exact mechanism by which induction of ovulation and regular cycles are induced is yet unknown. Alteration of the ovarian surface including the underlying tissue particularly the atretic follicles leads to a significant postoperative change of the pathophysiological mechanism. The following factors are postulated to be responsible for postoperative ovulation: 1. The drainage of the follicular fluid which contains high androgen levels results in an acute reduction of the intraovarian androgen level. 2. With coagulation and/or vaporization of the atretic follicles androgen production is significantly limited. 3. This localized reduction of androgen decreases their inhibitory effect on follicular maturation. 4. Lowered androgen levels result in diminished peripheral conversion of androgen to oestrogen and decreased positive feedback on LH production. 5. The secondary reduction of ovarian inhibin permits a rise of FSH secretion which results in a normal LH:FSH ratio.