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Chapter 15
Polycystic Ovarian Disease (PCOD) 
(also called PCOS)

from the book How to Have a Baby: Overcoming Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.

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Patients suffering from polycystic ovarian disease (PCOD ) have multiple small cysts in their ovaries ( the word poly means many). These cysts occur when the regular changes of a normal menstrual cycle are disrupted. The ovary is enlarged; and produces excessive amounts of androgen and estrogenic hormones. This excess, along with the absence of ovulation, may cause infertility. Other names for PCOD are polycystic ovarian syndrome (PCOS) or the Stein-Leventhal syndrome.

Diagnosis

PCOD (also called PCOS) can be easy to diagnose in some patients. The typical medical history is that of irregular menstrual cycles, which are unpredictable and can be very heavy ; and the need to take hormonal tablets (progestins) to induce a period. Patients suffering from PCOD are often obese and may have hirsutism , (excessive facial and body hair) as a result of the high androgen levels. However, remember that not all patients with PCOD will have all or any of these symptoms.

This diagnosis can be confirmed by vaginal ultrasound, which shows that both the ovaries are enlarged; the bright central stroma is increased ; and there are multiple small cysts in the ovaries. These cysts are usually arranged in the form of a necklace along the periphery of the ovary. Typically, blood levels of hormones reveal elevated levels of androgens ( a high dehydroepiandrosterone sulphate ( DHEA-S) level) ; a high LH level; and a normal FSH level.

Fig 1. A schematic, comparing a polycystic ovary with a normal ovary.

We don't really understand what causes PCOD (also called PCOS). However, we do know that the characteristic polycystic ovary emerges when a state of anovulation persists for a length of time. Patients with PCO have persistently elevated levels of androgens and estrogens, which set up a vicious cycle. Obesity can aggravate PCOD because fatty tissues are hormonally active and they produce estrogen which disrupts ovulation . Overactive adrenal glands can also produce excess androgens, and these may also contribute to PCOD.

Fig 2. The self-perpetuating vicious cycle of elevated levels of androgens and estrogens in PCOD

Treatment

Treatment of PCOD for the infertile patient will usually focus on inducing ovulation to help them conceive.

Weight loss: For many patients with PCOD, weight loss is an effective treatment - but of course, this is easier said than done! Look for a permanent weight loss plan - and referral to a dietitian or a weight control clinic may be helpful. Crash diets are usually not effective.

Increasing physical activity is an important step in losing weight. Aerobic activities such as walking, jogging or swimming are advised. Try to find a partner to do this with, so that you can help each other to keep going.

Ovulation Induction: The drug of first choice is clomiphene; this may be combined with low-doses of dexamethasone, a steroid which suppresses androgen production from the adrenal glands. Just taking clomiphene is not enough , and you need to be monitored ( usually with ultrasound scans) to determine if the clomiphene is helping you to ovulate or not. The doctor may have to progressively increase the dose till he finds the right does for you. If clomiphene does not work, HMG can be used. Some doctors prefer to use pure FSH for inducing ovulation in PCOD patients because they have abnormally high levels of LH. Ovulation induction can often be difficult in patients with PCOD , since there is the risk that the patient may over-respond to the drugs, and produce too many follicles, which is why the risk of ovarian hyperstimulation syndrome ( OHSS) and multiple pregnancy is often increased in patients with PCOD. The doctor has to find just the right dose of HMG ( called the threshold value ) in order to induce maturation and release of a single , or only a few follicles , and this can sometimes be very tricky. Difficult patients may also need a combination of a GnRH analog (to stop the abnormal release of FSH and LH from the pituitary) and HMG to induce ovulation successfully. Doctors have now learned that many patients with PCOD also have insulin resistance – a condition similar to that found in diabetics, in that they have raised levels of insulin in their blood ( hyperinsulinemia) , and their response to insulin is blunted. This is why some patients with PCOD who do not respond to clomiphene are treated with antidiabetic drugs, such as metformin and troglitazone. Studies have shown that these drugs can help to improve their fertility by reversing their endocrine abnormality and thus improving their ovulatory response.

Surgery: A recent treatment option uses laparoscopy to treat patients with PCOD. During operative laparoscopy, a laser or cautery is used to drill multiple holes through the thickened ovarian capsule. This procedure is called laparoscopic ovarian cauterisation or ovarian drilling or LEOS ( laparoscopic electrocauterisation of ovarian stroma) . Destroying the abnormal ovarian tissue helps to restore normal ovarian function and helps to induce ovulation. For young patients with PCO ovaries on ultrasound, if clomiphene fails to achieve a pregnancy in 4 months time, we usually advise laparoscopic surgery as the next treatment option, This is because LEOS helps us to correct the underlying problem; and about 80% of patients will have regular cycles after undergoing this surgery, of which 50% will conceive in a year’s time, without having to take further medication or treatment. Having regular cycles without having to take medicines each month can be very reassuring to these patients ! The risk of this surgery is that it can induce adhesion formation, if not performed competently.

In the past, doctors used to perform ovarian surgery called wedge resection to help patients with PCOD to ovulate. The removal of the abnormal ovarian tissue in the wedge breaks the vicious cycle of PCOD, helping ovulation to occur . While wedge resection used to be a popular treatment option, the risk of inducing adhesions around the ovary as a result of this surgery has led to the operation being used as a last resort.

For patients who do not respond to the above measures, intrauterine insemination is the next step. Some difficult patients with PCO may also need IVF in order to get pregnant. While PCO patients usually grow many eggs, quite a few of these may be immature, so that fertilization rates may be lower than average. Also, because of the PCOD, the risk of ovarian hyperstimulation syndrome is increased in these patients.

The good news is that with the currently available treatment options, successful treatment of the infertility is usually possible in the majority of patients with PCOD.

by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.

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