Dr. Adamson is CEO of Advanced Reproductive Care Inc., and receives research support from IBSA.
The diagnosis and treatment of fertility are evolving rapidly as a result of clinical studies, scientific research, and changing socioeconomic and ethical perspectives. These developments benefit health-care consumers, but they also pose new challenges to general ObGyns and other practitioners committed to the best possible care for their patients.
In this Update, I focus on a number of these areas of change:
- care of women who have polycystic ovary syndrome (PCOS)
- the impact of myomas on fertility
- treatment of infertility in women who have endometriosis
- when tubal reconstruction is appropriate
- the impact of a woman’s age on fertility
- patient-friendly strategies to enhance fertility
- cross-border reproductive travel.
Use clomiphene citrate to stimulate ovulation in women who have PCOS
Practice Committee of the American Society for Reproductive Medicine. Use of insulin-sensitizing agents in the treatment of polycystic ovary syndrome. Fertil Steril. 2008;90(5 Suppl):S69–S73.
A new Committee Opinion from the American Society for Reproductive Medicine (ASRM) Practice Committee tackles the challenge of treating women with PCOS for infertility.
PCOS is associated with an increased risk of insulin resistance and diabetes mellitus. The first line of treatment for all women who have PCOS, especially those with an elevated body mass index, is lifestyle modification through diet and exercise, with the goal of losing weight.
Clomiphene is first-line therapy when ovulation is the aim
Metformin and other insulin-sensitizing agents may enhance ovulation and increase the response to clomiphene citrate in women who have PCOS and insulin resistance, but their use solely to enhance ovulation is unwarranted, and they do not reduce the rate of miscarriage. Clomiphene citrate should be the first-line treatment because it is much more effective. Long-term use of metformin to prevent disease is not advised.
Screen for insulin resistance at the time of diagnosis
Women who have PCOS should be given a 2-hour oral glucose tolerance test and have their lipid profile measured at the time of diagnosis and then at an interval of every 2 years. Insulin-sensitizing agents should be used for long-term health issues only after impaired glucose tolerance has been measured, if diet and exercise alone prove to be ineffective.
My strategy for stimulating ovulation in this population involves the following:
- Perform vaginal ultrasonography (US) on cycle day 3 for an antral follicle count and to rule out ovarian cysts >1 cm.
- Give clomiphene citrate, 50 mg, on cycle days 3 through 7 (or 5 through 9).
- Repeat vaginal US on cycle day 11 (or 13) to evaluate ovarian response. The optimal response is 1 to 2, and not more than 3, follicles ≥15 mm in size.
- Recommend timed intercourse, starting on cycle day 10 and then every 2±0.5 days until 1 to 2 days after ovulation.
- Measure urinary luteinizing hormone (uLH) daily, to detect uLH surge, starting on cycle day 11. A positive surge indicates that ovulation is likely within the next 12–48 hours. Absence of a surge indicates the likely absence of ovulation, which can be treated by giving 10,000 IU of human chorionic gonadotropin (hCG) subcutaneously or intramuscularly when the largest follicle is 18 to 25 mm in size.—G. DAVID ADAMSON, MD
When choosing a treatment for myoma, consider impacts on fertility
Practice Committee of the American Society for Reproductive Medicine in collaboration with the Society of Reproduction Surgeons. Myomas and reproductive function. Fertil Steril. 2008;90(5 Suppl): S125–S130.
A recent educational bulletin from the ASRM Practice Committee examined the relationship between myomas and reproductive function and reviewed management of this pathology.
The effects of myomas on reproductive outcome are ill-defined, but fibroids that distort the uterine cavity, as well as larger intramural myomas, may have adverse effects on fertility.
Select interventions carefully
Among women who have infertility and those who have recurrent pregnancy loss, myomectomy should be considered only after thorough evaluation. The reason? Postoperative adhesions as a result of abdominal myomectomy are common and may reduce subsequent fertility.
As for uterine artery embolization, myolysis, and MRI-guided ultrasonic treatment, these are not recommended for women who have myomas and who are seeking to maintain or improve fertility. The safety and efficacy of these procedures in this population have not been established.