What Is the Connection Between PCOS and Infertility?

Polycystic ovary syndrome (PCOS) is a syndrome of endocrine disorders characterized by rare or anovulatory ovulation, high androgen or insulin resistance, and polycystic ovary. Symptoms include thin menstruation or amenorrhea, chronic anovulation, infertility, hairiness, and acne. Due to continuous anovulation, the endometrium is hyperproliferated in severe cases, increasing the risk of endometrial cancer. The choice of treatment plan is very complicated, and it varies according to different symptoms and fertility requirements. Needs long-term attention.

Basic Information

nickname: Polycystic ovary syndrome, Rokitansky tumor, sclerosing cystic ovary syndrome
English name: polycystic ovarian syndrome

Visiting department: Gynecology
Common symptoms: Thin menstruation, amenorrhea, anovulation, infertility, hairy, acne
Contagious: no

Causes of PCOS

The etiology of PCOS is unknown and the pathological mechanisms involved are very complex. Generally believed to be related to hypothalamic-pituitary-ovarian axis dysfunction, adrenal dysfunction, genetics, metabolism and other factors.

Genetic factors

PCOS is a disease caused by an autosomal dominant inheritance, or X-linked (sexual) inheritance, or a genetic mutation. Most patients have karyotype 46, XX, and some patients have chromosomal aberrations or chimeric types such as 46, XX / 45, XO / 46, XX / 46, XXq and 46, XXq.

2. Adrenal emergence hypothesis

PCOS originates from prepubertal adrenal disease, that is, when the reticular zone secretes too much androgen when it is stimulated by strong stress, and it is converted into estrone outside the gonads, which causes the HP axis GnRH-GnH release rhythm disorder, LH / FSH The increase in the ratio leads to an increase in ovarian androgen production, that is, the adrenal gland and the ovary secrete more androgens to cause hyperandrogenemia. Hyperandrogenemia causes thickening of fibrosis of the capsule in the ovary, inhibits follicular development, causes cystic enlargement of the ovary and chronic anovulation.

Chinese medicine believes that this disease is mainly due to kidney deficiency, phlegm dampness, qi stagnation and blood stasis, and dampness and heat of the liver meridian.

PCOS clinical manifestations

Abnormal menstruation

Rare menstruation, amenorrhea, a few can be expressed as functional uterine bleeding. Mostly occur in adolescence, irregular menstruation after menarche.

Hairy

More common, the incidence can reach 69%. Due to the increase in androgen, it can be seen that the hair on the upper lip, lower jaw, chest, back, lower abdomen, upper sides of the thighs, and perianal area is thickened and increased, but the degree of hairiness is not proportional to the androgen level. At the same time, it can be accompanied by acne, excessive facial sebum secretion, low voice, thickened clitoris, and masculine signs such as larynx.

3. Infertility

Due to long-term ovulation, patients are often complicated with infertility, and occasional ovulation or miscarriage may occur, the incidence rate can reach 74%.

4. Obesity

Those who weighed more than 20% and had a body mass index of 25 or more accounted for 30% to 60%. Obesity is mostly concentrated on the upper body, waist / hip ratio> 0.85. It usually starts from puberty and gradually increases with age.

5. Black Acanthosis

Gray-brown pigmentation appears on the skin folds of the labia, neck and back, underarms, under breasts, and groin, and is symmetrical, with thickened skin and soft texture.

6. Ovary enlargement

A small number of patients can reach the enlarged and tough ovaries through general gynecological examination, and most of them need to be confirmed by B-ultrasound.

7. Estrogen effect

Due to non-ovulation, progesterone cannot be produced. For example, long-term estrogen stimulation of the endometrium can cause hyperplasia of the endometrium, atypical hyperplasia, and even canceration.

PCOS inspection

Hormone determination

Increased testosterone and (or) serum LH / FSH 2.5 to 3: About 75% of patients have increased LH, and the ratio and concentration of blood LH to FSH are abnormal.

2. Imaging examination

(1) The ovarian B ultrasound has enlarged ovaries. There are at least 10 follicles with a diameter of 2 to 6 mm per plane, which are mainly distributed around the ovarian cortex.

(2) The bilateral ovaries of the pneumoperitoneum are enlarged by 2 to 3 times. If the main source of androgens is the adrenal glands, the ovaries are relatively small.

(3) Laparoscopy (or during surgery) shows that the ovary is full, the surface is pale and smooth, the capsule is thick, and sometimes there is a capillary network under it. Due to its pearl-like appearance, it is commonly known as oyster ovary, with multiple cystic follicles visible on the surface.

(4) Transvaginal ultrasound Transvaginal ultrasound can detect polycystic ovary 100%, and 30% of patients missed diagnosis. For unmarried obese patients, anal ultrasound can be used to detect. It can be seen that there are more than 10 non-echoic areas with a diameter of 2-9mm on one or both sides of the ovary. Continuous monitoring showed no signs of dominant follicular development and ovulation. The ultrasound phase of some PCOS patients is normal.

(5) Other obese people should measure fasting blood glucose and oral glucose tolerance test. Fasting insulin and serum insulin after glucose load should also be measured. Obese patients may have increased triglycerides.

3. Laparotomy

Performed when a ovarian tumor is to be diagnosed or wedge resection is desired.

4. Other inspections

(1) The maturity index of vaginal exfoliated cells is a simple method to understand the status of sex hormones in the body. Smears with too much testosterone tend to have three layers of cells, and the number of cells in the three layers is almost equal when it is significantly increased, but it must be distinguished from inflammation. Estrogen levels can be estimated from the percentage of surface cells, but do not reflect the level of hormones in the blood.

(2) Basal body temperature measurement determines whether ovulation occurs. Those who have ovulated are biphasic, those who have no ovulation are generally single-phase.

PCOS diagnosis

Clinical diagnosis

After menarche for many years, menstruation is still irregular, menstruation is rare and / or amenorrhea, accompanied by obesity and hairiness, infertility after marriage, etc., PCOS should be suspected. Typical cases have the above-mentioned symptoms and signs, namely menstrual disorders, hairy, acne, obesity, infertility and so on. Atypical cases can be manifested as: Simple amenorrhea is not accompanied by obesity, hairyness, and ovarian enlargement, and other various diseases are excluded. Those with positive progesterone test should still be considered PCOS. Ovulation type dysfunctional bleeding. Menstrual abnormalities combined with hairy. Abnormal menstruation with virilization symptoms, no obvious obesity. Dysfunctional uterine bleeding with infertility.

For atypical cases, you need to ask about the medical history in detail, such as the age of onset, growth and development, history of onset, history of medication, family history, personal habits, and previous systemic diseases. Combined with auxiliary examinations to exclude other diseases, and confirmed by B-ultrasound and other tests.

2. Diagnostic criteria

Due to the heterogeneity of the disease, the diagnostic criteria have not been unified. Most scholars are based on adolescent onset, abnormal menstruation and ovulation, hairy, elevated blood LH and / or LH / FSH ratios, combined with excessively high androgen levels, and many ultrasound examinations. Signs of cystoovarian disease can be confirmed after excluding other similar diseases.

PCOS treatment

1. Obesity and insulin resistance

Increase exercise to reduce weight, correct endocrine and metabolic disorders exacerbated by obesity, reduce insulin resistance and hyperinsulinemia, reduce IGF-1, increase IGfBP-1, and increase SHBG decrease free androgen levels. Weight loss can restore ovulation in some obese PCOS patients and prevent the occurrence of type 2 diabetes and cardiovascular disease. Metformin treatment can be used with or without diabetes, which can effectively reduce weight, improve insulin sensitivity, reduce insulin levels, reduce hair and even restore menstruation (25%) and ovulation. Because obesity and insulin resistance are the main causes of PCOS, all drugs that can reduce weight and increase insulin sensitivity can treat this syndrome.

2. Drug-induced ovulation

(1) Clomiphene is the drug of choice for PCOS, with an ovulation rate of 60% to 80% and a pregnancy rate of 30% to 50%. Clomiphene competes with endogenous estrogen receptors at the hypothalamic-pituitary level, inhibits negative feedback of estrogen, and increases the pulse frequency of GnRH secretion, thereby adjusting the secretion ratio of LH to FSH. Clomiphene also directly promotes ovarian synthesis and secretion of estrogen. After taking this medicine, the ovaries are enlarged due to excessive stimulation (13.6%), vasodilatation with a fever (10.4%), abdominal discomfort (5.5%), blurred vision (1.5%), or a rash and mild hair loss, etc. side effect.

During treatment, the basal body temperature of the menstrual cycle should be recorded, ovulation monitored, or serum progesterone and estradiol should be measured to confirm the existence of ovulation and guide the adjustment of the dose for the next course of treatment. If 6 or 12 months after clomiphene treatment is still not ovulating or pregnant, can be given clomiphene plus HCG or glucocorticoids, bromocriptine treatment or treatment with HMG, FSH, GnRH.

(2) Combination of clomiphene and chorionic gonadotropin (HCG). Chlorophene (HCG) was added on the seventh day after clomiphene was discontinued.

(3) The effect of glucocorticosteroids combined with clomiphene on adrenocortical hormones is based on its ability to inhibit excessive androgen secreted from the ovaries or adrenals. Dexamethasone or prednisone is usually selected. The effective rate was 35.7% within 2 months, and the ovarian function of amenorrhea in amenorrhea was restored. When clomiphene is not effective in inducing ovulation, dexamethasone can be taken simultaneously during the treatment cycle.

(4) Urotropin (HMG) is mainly used in patients with reduced secretion of endogenous pituitary gonadotropin and estrogen. Urotropin (HMG) is an extract purified from the urine of menopausal women and contains FSH And LH, the ratio of the two is 1: 1, each ampoule contains FSH and LH 75U each. Urotropin (HMG) is considered as an alternative ovulation-inducing drug for the treatment of anovulatory infertility. Because of its many side effects, the risk of ovarian hyperstimulation syndrome (OHSS) is greater. The therapeutic dose of chorionic gonadotropin (HCG) should vary from person to person and the treatment cycle, and strict monitoring measures for follicular maturation should be provided to prevent the occurrence of ovarian hyperstimulation syndrome (OHSS).

(5) GnRH GnRH can promote the release of FSH and LH from the pituitary gland, but long-term application makes the GnRH receptors of the pituitary cells insensitive, leading to a decrease in gonadotropin, thereby reducing ovarian sex hormone synthesis. Its effect is reversible, and it begins to excite the pituitary FSH, LH, and ovarian sex hormones. It drops to normal levels after 14 days and reaches castrated levels on 28 days. However, because GnRH-A is expensive and used in large amounts, its clinical application is limited.

(6) There are two types of FSH FSH, purified and recombinant human FSH (rhFSH). FSH is an ideal treatment for polycystic ovary, but it is expensive. And may cause OHSS. During application, ovarian changes must be closely monitored. FSH can also be used in combination with GnRH-A to improve the success rate of ovulation.

(7) Bromocriptine is suitable for ICOS patients with high PRL after meals.

3. Bilateral ovarian wedge resection

It is suitable for those with elevated blood testosterone, bilateral ovaries, and normal DHEA and PRL (indicating that the main cause is in the ovary). Part of the ovary is removed to remove excessive androgen from the ovary, which can correct the hypothalamic-pituitary-ovarian axis adjustment. Disorders, but the site of the resection and the amount of tissue removed are related to the efficacy and the effectiveness varies. The pregnancy rate is 50% to 60%. The postoperative recurrence rate is high, such as concurrent pelvic adhesions, is not conducive to pregnancy. Laparoscopic cautery or resection of the ovaries can also have some effects.

4. Treatment for hirsutism

It can be cut off or coated with "hair loss agents" regularly, and should not be removed to prevent excessive growth of hair follicles. It can also be used as an electro-erosion treatment or an androgen-inhibiting drug treatment.

(1) Oral contraceptive estrogen and progestin composite tablets, which are mainly estrogen, are ideal. They can inhibit LH secretion, reduce blood testosterone, androstenedione and DHEAS, and increase the concentration of sex hormone binding globulin.

(2) Progestin has weak anti-androgens and mildly inhibits gonadotropin secretion, which can reduce testosterone and 17-ketosteroid levels. Medroxyprogesterone (progesterone) is more commonly used. Usually taken orally. In addition, the cycloprogesterone acetate (CPA) is a highly potent progesterone and has a strong anti-androgenic effect. Often taken with ethinylestrone.

(3) GnRH-A is used on the 1st to 5th days of the menstrual cycle, and various preparations such as percutaneous inhalation, subcutaneous and intramuscular injection are available. At the same time, taking ethinylestrone can avoid adverse reactions caused by estrogen after medication.

(4) Dexamethasone is suitable for adrenal-derived hyperandrogens and is taken orally every night.

(5) Spironolactone can interfere with the synthesis of ovarian androgens by preventing testosterone from binding to the receptor of the hair follicle, and also by inhibiting 17-enzyme. Can reduce the patient's hair growth, hair becomes thinner. Hypermenorrhea with menstrual disorders without ovulation can be used on the 5th to 21st days of menstruation, which can restore the menstrual cycle and ovulation in some patients.

5. Artificial Menstrual Cycle

For patients without hairiness and without fertility requirements, artificial cycle therapy can be given to progestins to avoid excessive proliferation and canceration of the endometrium.

PCOS prognosis

Diabetes

Patients with polycystic ovary syndrome have hyperinsulinemia. Patients with hyperinsulinemia are prone to diabetes and cardiovascular and cerebrovascular diseases. Therefore, polycystic ovary syndrome is also a high risk factor for diabetes and cardiovascular and cerebrovascular diseases.

Endometrial cancer

According to statistics, 19% to 25% of patients with endometrial cancer 40 years of age have PCOS, and some PCOS can progress to endometrial cancer.

PCOS prevention

1. Obese patients with polycystic ovary should lose weight scientifically

Obese patients with polycystic ovary syndrome (BMI> 24) should lose weight in an effective and healthy manner: Including about 500 calories less daily calorie intake, so that weight can be reduced at a safe rate of about 2 kg per month.

2. Optimize diet for the treatment of polycystic ovary syndrome

Diet adjustment is an important adjuvant treatment for PCOS. In addition to total calories, care should be taken in choosing food for patients who have reached the standard weight or were originally not obese. In order to prevent the diet from causing insufficient absorption, supplement 500-1500 milligrams (mg) of calcium tablets and a comprehensive vitamin containing 400 micrograms (mcg) of folic acid daily, and the amount of water should be 8 glasses of water per day; in order to avoid abnormal blood lipids , Eat less foods containing saturated fatty acids and hydrogenated fatty acids, such as pork, beef, mutton, fatty meat, various poultry and livestock skins, butter, artificial cream, whole milk, fried food, Chinese and Western pastries; fish, protein, beans, nuts Is a better source of protein.

3. Do the right amount of exercise

Regular exercise can help control blood sugar, blood lipids, and blood pressure.