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Polycystic Ovarian Syndrome

Polycystic ovarian syndrome (PCOS), which is a complex genetically transmitted disease and the cause of which is not known exactly, is the most common hormonal disorder in women of reproductive age. Its incidence varies according to the diagnostic criteria used, but it is around 8-13% on average. However, it is more likely to be seen in people who have trouble getting pregnant, have overweight, insulin resistance or diabetes, have early onset of body hair and have PCOS in their close relatives.

What are the Symptoms of Polycystic Ovarian Syndrome (PCOS)?

The most common symptom is menstrual irregularity that continues from the age when patients first start menstruating. Every patient does not need to have this symptom but most of the patients mentions about menstrual irregularity. It is considered normal for the menstrual cycle to be every 21-35 days from the first day to the first day of the next period. In patients with menstrual irregularity, menstrual intervals may be every 45-60 days, or in some patients, it may be on the verge of not having a menstrual period without medication.

An increase in hair growth in the male-pattern areas of the body is another indication that is observed in most of the patients. In other words, hair growth is frequently seen on the face, nipples, waist, arms and thighs where hair growth is not normally seen especially in women. More than normal hair loss, thinning hair, oily skin and acne complaints increase in most women too.

In addition, some patients have increased insulin resistance, hyperinsulinism, increased blood sugar levels, high blood lipid levels, and a tendency to gain male-type weight gain, that is, fat in the abdomen and belly.

Clinical Findings: 

If 2 of the 3 findings below are present in our patient, we diagnose her as having PCOS. 

  • Menstrual irregularity (usually 6-8 or fewer periods per year) that is often seen from adolescence may be in the form of infrequent menstruation in the majority of patients, while in some, it may be in the form of absence of menstruation without medication. However, this is not the rule, regular periods may be seen in some patients.
  • Androgen hormone elevation causing male pattern hair growth (above the lips, chin, nipples, thighs, arms and waist) increase, intense hair loss and acnes as a clinical reflection or only high androgen hormone (testosterone, DHEAS, androstenedione) levels in the blood can be detected.
  • In the past, the presence of more than 12 egg sacs (antral follicles) of 2-9 mm in size in both ovaries in the ultrasonographic evaluation was considered as a polycystic ovary image. However, today, thanks to highly sensitive ultrasonography devices, this number has been updated as more than 20 antral follicles for each 2 ovaries.

How is PCOS diagnosed?

For the diagnosis of PCOS, The Androgen Excess and PCOS Society criteria, National Institute of Health (NIH) criteria or Rotterdam criteria can be used. Rotterdam criteria are the frequently used one today.

In accordance with the Rotterdam diagnostic criteria, we diagnose the patient as having PCOS, if 2 of the 3 findings below are present.

  • Menstrual irregularity (usually 6-8 or fewer periods per year) that is often seen from adolescence may be in the form of infrequent menstruation in the majority of patients, while in some, it may be in the form of absence of menstruation without medication. However, this is not the rule, regular periods may be seen in some patients.
  • Androgen hormone elevation causing male pattern hair growth (above the lips, chin, nipples, thighs and arms and waist) increase, intense hair loss and acnes as a clinical reflection, or only high androgen hormone (testosterone, DHEAS, androstenedione) levels in the blood can be detected.
  • In the past, the presence of more than 12 egg sacs (antral follicles) of 2-9 mm in size in both ovaries in the ultrasonographic evaluation was considered as a polycystic ovary image. However, today, thanks to highly sensitive ultrasonography devices, this number has been updated as more than 20 egg sacs for each 2 ovaries.

Parameters to Consider in Polycystic Ovarian Syndrome

Approximately half of the patients are overweight. Insulin resistance and hyperinsulinism are observed in most of the patients, regardless of excess weight. Those with insulin resistance may also need to lose weight and use medication when necessary. At the same time, the risk of developing type 2 diabetes increases throughout life in the presence of PCOS.

There is also an increased risk of developing coronary heart disease in those with insulin resistance or diabetes, in addition to high blood lipid levels in PCOS patients.

In the presence of PCOS, besides the increase in the frequency of depression and anxiety, the possibility of eating disorders also increases.

The risk of thickening (hyperplasia) or cancer in the inner wall of the uterus may increase in patients with menstrual irregularity who have 3-4 months between periods or less frequent menstrual periods and whose regularity cannot be achieved with medical treatment.

Treatment of Polycystic Ovarian Syndrome

The treatment is planned according to whether the woman have a desire of pregnancy.

Can Women with Polycystic Ovarian Syndrome get Pregnant?

Women with polycystic ovary syndrome can achieve pregnancy effectively after they are evaluated as a couple and the appropriate treatment method is determined. In fact, the possibility of pregnancy without the need for IVF may be quite high in couples who do not have any additional problems related to either the woman or the man, and where the woman’s age is young.

In this scope;

Treatment in the period where there is not a planning for pregnancy;

Regulation of the life style should be the primary aim here. Thereby, providing weight loss with regular nutrition, a diet low in carbohydrates and increasing exercise will help initiation of ovulation function in some patients and may ensure regular menstruation. Even loss of 5-10% of body weight can be beneficial to regulate menstruation. So, losing 4-8 kg for a woman whose weighs 80 kg can ensure regular menstruation without any need for the treatment. Meanwhile, weight loss will contribute to the improvement of insulin resistance and blood lipid values to be in the normal range.

Androgen deprivation drugs can also be used in order to prevent excess hair growth in patients who cannot benefit from using birth control pills for 6 months or who do not want to use birth control pills. However, in cases where this treatment is applied, it should be reminded that pregnancy should be avoided absolutely.

The treatment methods applied prevent the growth of new hairs. Thus, epilation methods should be applied in order to destroy the existing hairs.

Menstrual Irregularity Treatment in PCOS

Having regular menstruation periods is important in PCOS patients. Because menstruation at intervals infrequent than 2 months causes the inner wall of the uterus to remain under the influence of estrogen solely and if regular bleeding is not provided with drugs, problems such as hyperplasia that can turn into malignant diseases in neglected patients and cause an increase in the risk of cancer of the inner wall of the uterus in the following years. Therefore, as a recommendation to be followed, it is important to follow the menstrual cycle of the person and to use medication when necessary.

The most commonly used drugs in this context will be combined birth control pills. This type of treatment can be considered especially in patients with increased body hair growth, to prevent the development of new hairs, to reduce the complaints of oily skin and acne, to regulate menstruation and to prevent pregnancy in cases with regular menstruation.

Use of cyclic progesterone can also be considered to protect the inner wall of the uterus in cases with irregular menstruation and for people who do not want to use birth control pills. In the absence of menstruation, the use of progesterone-containing drugs for 10-14 days every 2 months may be recommended in this regard. However, this treatment will not provide a solution to the problem of excess hair growth and acne.

What are the risks that can be encountered in polycystic ovary syndrome?

Approximately half of the patients have overweight problem. Most of the patients have insulin resistance and hyperinsulinism, regardless of excess weight. Weight loss may be beneficial for those with insulin resistance, and the use of metformin-derived drugs can be considered if necessary. Meanwhile, the risk of developing type 2 diabetes during life increases in the presence of PCOS.

In addition to high blood lipid levels in PCOS patients, insulin resistance or diabetes will pose an increased risk of developing coronary heart disease.

Again, an increase in the frequency of depression and anxiety and an increase in the possibility of eating disorders have also been reported in the presence of PCOS.

Having menstrual irregularity may pose a risk for the thickening (hyperplasia) or cancer in the inner wall of the uterus in those whose intervals between periods are 3-4 months or less frequent and are not regulated by medical treatment.

Treatment in the presence of polycystic ovarian syndrome

In the period where there is not a planning for pregnancy;

We recommend to implement a diet and exercise program that will provide weight loss for those who have menstrual irregularity due to overweight and lack of ovulation. In many patients, 5-10% weight loss can improve ovarian function and also contributes positively to insulin resistance and blood lipid levels. If the patient is also willing and diligent, establishing a low-calorie nutrition program and making exercise a lifestyle will enable ovulation without treatment and pregnancy if there is no additional problem.

In patients with menstrual irregularity, it is important to determine whether spontaneous ovulation occurs, especially if the intervals are longer than 35 days. In this context, from the 21st day of menstruation until get the next menstruation, weekly progesterone hormone measurement can be made in the blood. If the progesterone level in the blood is above 3ng/ml, it is considered as the presence of ovulation.

In the period where there is a planning for pregnancy;

Determining whether spontaneous ovulation occurs is important in patients with menstrual irregularity, especially if the intervals are less than 35 days. In this context, from the 21st day of menstruation until next menstruation, weekly progesterone hormone measurement can be performed in the blood. The progesterone level above 3ng/ml in the blood is considered as the presence of ovulation.

If there is no ovulation in the patient and there is no situation that will cause an additional pregnancy problem for the woman or the man, the first-line treatment is the pill treatments that provide ovulation. Pill treatments are easy to use and inexpensive. Ultrasonography follow-up is not required during the use of these drugs. Approximately 30-40% of patients can achieve pregnancy after 6 months of use at the dose at which ovulation is achieved.

Especially in couples who are young, who do not have obesity, which means that not overweight to the point of disease, the probability of ovulation is higher with these pills. If ovulation cannot be obtained when measured with a blood test, the dose of the drug is increased and another attempt will be done. If ovulation cannot be achieved with the highest recommended dose of the drug or if pregnancy is not achieved despite ovulation, second-line treatment can be started.

The second-line treatment option is low-dose daily injection therapy. In order to stimulate ovulation, drugs called gonadotropins will be used in very low daily doses to enlarge 1 or 2 egg sacs, namely follicles. When the follicles reach the desired size, a final shut injection is applied. With this method, ovulation can be achieved in 95% of patients. Pregnancy rates are around 23-25% when intrauterine insemination when added. IVF treatment should be started in patients who cannot achieve pregnancy despite 2 or 3 attempts.

However, ovarian stimulation with daily injection requires experience and precision. Use of the drug in excessive doses and an unproper follow-up will cause an uncontrolled number of excess follicle development and the risk of multiple pregnancy such as triplets, quadruplets and quintuplets and the risk of developing overstimulation syndrome (OHSS) will arise. Therefore, performance of this treatment by an experienced reproductive specialist is important here.

Ovarian drilling was commonly performed to reduce androgenic hormone production by laparoscopically making holes in the ovary with the effect of heat in patients who did not respond to ovulation treatment with pills in the past. Thus, spontaneous ovulation could be achieved in some patients with the reduction of the androgenic hormone produced. Today, however, this procedure has been avoided due to the fact that this procedure is a surgical procedure, adhesions can develop in the abdomen after the operation, unresponsiveness to the new generation pill treatment is almost non-existent, and there are effective daily injection treatments options.

In vitro fertilization, which is the third treatment option, is the treatment method with the highest chance of pregnancy and the chance of pregnancy is much higher in patients with polycystic ovary syndrome than in patients without.

Since more oocytes can be obtained than the rest and the possibility of blastocyst transfer at the 5th day after oocyte pickup increases, and choosing the best embryos on the day of transfer becomes possible. In addition, since a large number of embryos of good quality can be obtained, it is also possible to store the embryos other than the transferred embryos by freezing with the rapid freezing technique, namely, the vitrification method. In young age and patients who do not have an additional reason for not being able to get pregnant, up to 60%  pregnancy can be achieved with in vitro fertilization treatment.

However, ovarian stimulation during in vitro fertilization in the presence of PCOS requires experience. Because the weight gain is also included in the calculation, making it difficult to adjust the dose of the drug to which a response can be obtained. Giving more drugs than necessary may cause an exaggerated response and an increase in the risk of developing overstimulation syndrome (OHSS), and using drugs in low doses may cause the target number of oocytes not to be reached.


Evaluating the response obtained after ovarian stimulation and making a treatment plan accordingly, especially in the presence of PCOS, is also important. It is important for patient safety that all embryos obtained are frozen and fresh transfer is not made in order to avoid the risk of OHSS in cases with more than 18 follicles with a size greater than 11 mm on the day of the day of final shut injection after ovarian stimulation in IVF.

Since the ovaries are much more viable than their peers in this group of patients, choosing the appropriate drug protocol, adjusting the drug doses used according to the patient, choosing the final shut injection type appropriately, and transferring with thawing application after freezing and storing all embryos instead of fresh transfer when required is very important in terms of patient safety and minimizing the risk of ovarian hyperstimulation syndrome (OHSS).

Contact information :

Author : Prof. Dr. Mehtap Polat
Telephone : +90 530 011 41 33
E-mail : [email protected]

Prof. Dr. Mehtap Polat

18 yılı aşkın meslek hayatım boyunca mesaimin neredeyse tama yakını bebek sahibi olmak isteyen çiftlere yönelik tedavilerle geçti. Çocuk isteği olan ve tedavi gereği olan çiftlerin bu süreçte ne kadar kırılgan, naif ve hassas olduklarının farkındayım. Bu nedenle hastalarımla yaptığım ilk görüşme anından itibaren, kendilerine olabilecek en yüksek başarı oranını sunmak için bilimsel veriler ışığında güncel, kaliteli, özenli ve çifte özel bireyselleştirilmiş tedavi uygulamanın gayreti içindeyim..
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