Fertility Care and Endoscopy

PCOS hugely impacts the women’s reproductive career and it’s one of the primary causes of anovulatory infertility. The prevalence of PCOS is 40% in women with infertility, which is very high for a particular disorder. Together with menstrual irregularities, hyperandrogenic manifestations, Infertility is one of the prime cause of concern and may be the presenting complaint.

Dr.Shraddha’s PCOS Clinic follows Integrated, individualized, comprehensive, scientifically designed, multifaceted approach to address all aspects of Infertility associated with PCOS. Personalized approach is the cornerstone of our management!

DONOT FRET, WE ARE ON YOUR WAY!!!

How PCOS Causes Infertility

Abnormal Follicle Development

Primary cause of Infertility in PCOS women. This defect is at the level of ovary where multiple follicles are formed in absence of single dominant follicle. Testosterone high in follicular fluid inhibits follicle maturation & lowers fertilisation.

Obesity/Insulin Resistance

Increased number of fat cells leads to raised leptin and insulin, Luteinizing hormone(LH) and decreased follicle stimulating hormone(FSH) and this disturbance in endocrine milieu leads to anovulation. Insulin affect the competence of oocyte development.

Raised Anti-Mullerian Hormone

High AMH present in women with PCOS plays an integral role in causing anovulation; by inhibiting FSH, hormone which normally promotes follicle development from the small antral stage to ovulation.

Look, How Do We Take Care Of Your Follicles!!

‘Transcending Infertile Barriers’

Pre-Conception Counseling

To emphasize the importance of life style, especially weight reduction and exercise in overweight women, abstinence from smoking & alcohol. Diet and physical activity plays a vital role as a first step to improve fertility in obese PCOS patients with anovulatory infertility.

Detailed History & Examination

Detailed History from both partners is the very first step of our unique approach followed by examination of both. This step reveals many minor issues & associated infertility factors, which went unnoticed if not properly enquired.

These may be ovulation defect, pre-menstrual spotting, tubal factors, fibroid, endometriosis,

erectile dysfunction, premature ejaculation etc.

Pre-Treatment Assessment

Both partners are investigated and evaluated for semen profile, hormonal profile, Antral follicle count and AMH to assess ovarian reserve so as to chose the most appropriate regimen for ovulation induction, with successful outcomes and fewer complications. Presence of other associated infertility factors is also probed into as treatment needs Individualization.

Ovulation Induction (OI)

Anovulation is the prime cause of infertility in PCOS patients. Based on age, BMI, ovarian reserve, duration of infertility, ovulation induction protocol is selected.

First line drugs for OI – Oral drugs

Clomiphene citrate is the first choice of treatment for OI in anovulatory women with PCOS. Follicular Monitoring with ultrasound is done to monitor ovulation and assess endometrial thickness.
Letrozole- It is better than Clomiphene as forms limited mature follicles hence less chance of multiple pregnancy. Moreover, it exerts no antiestrogenic effect on endometrium.

Adjuvants for ovulation induction are prescribed like insulin sensitisers, antioxidants and micronutrients to improve the conception rate.

‘Fertility Enhancing Surgery’

Hysteroscopy & Laparoscopy

Surgeries of hysteroscopy & laparoscopy are Mirror into abdomen and uterus. These scarless surgeries magnify the intrabdominal and intra-uterine view to reveal the anatomical distortion, causing infertility.

Diagnostic and Operative procedures are performed simultaneously to check for the patency of tubes, perform laparoscopic ovarian diathermy (ovarian drilling) in resistant cases of PCOS to restore spontaneous ovulation. Further, to diagnose & correct the associated factors of infertility like endometriosis, fibroid and adhesions, Endoscopy is the best option available and its contribution is revolutionary in present era.

For blocked tubes, we perform tubal cannulation, augment uterine cavity via hysteroscopy for hypoplastic uterus. uterine septum removed via hysteroscopy and myomas are removed, tubo-ovarian masses removed and normal tubo-ovarian relationship maintained in the same sitting. Thus, distorted anatomy is restored to normal by hysteroscopy and laparoscopy, hence termed as ‘FERTILITY ENHANCING SURGERIES ‘ so as to improve the fertility outcome.

WE PERFORM SCAR-LESS SURGERIES TO HEAL SCARS OF INFERTILITY !

Laparoscopic Ovarian Diathermy/Drilling(LOD)

LOD is reserved for Clomiphene citrate failure cases. Apart from exogeneous gonadotropins, it is second line of treatment in PCOS patients to restore spontaneous ovulation. Multiple Ovarian puncture performed either by diathermy or by laser is known as
Ovarian drilling.

BENEFITS OF LOD

LOD can achieve unifollicular ovulation with no risk of high order multiples.
Does not require intensive monitoring of follicular development, so favorable option for those who live far away from hospital.
No risk of Ovarian Hyper stimulation Syndrome ( OHSS) as seen with Gonadotropins.
Reduction in Multiple Pregnancy in women undergoing LOD makes this option attractive.

RISKS OF LOD

- Risk of Laparoscopy and anaesthesia.
- Risk of adhesion formation.
- Risk of destruction of normal ovarian tissue.

Hence Surgery Of LOD should be performed by appropriately trained personnel..

Use of LOD for OI in women with PCOS

Beneficial for Clomiphene resistant PCOS
As effective as OI with Gonadotropin injectables in terms of live births.
Reduces the need for OI or ART in significantly higher proprtion of women.

Gonadotropins

For resistant cases with oral therapy, besides LOD, Gonadotropins are recommended as second line of treatment; administered for ovulation induction. Stringent follicular monitoring is performed for patients on gonadotropin therapy. Exogeneous gonadotropins are associated with higher risk of multiple pregnancies and Ovarian Hyperstimulation Syndrome (OHSS).
To increase the success rate, Intrauterine Insemination is performed .

INTRAUTERINE INSEMINATION (IUI)

Technique of IUI is used to bypass the hostile cervical enviornment and directly inject the semen of husband or donor into uterine cavity. Thus, presence of sperm antibodies in cervical mucus is bypassed and fertility outcome is enhanced. With one cycle of IUI, pregnancy rate is 15-20% but with 3-6 cycles, success rate can be increased to 80%.

IN-VITRO FERTILISATION (IVF)

IVF is the recommended third line of treatment for resistant and severe cases of PCOS. IVF is more favorable for severe PCOS associated with tubal factors leading to Infertility. IVF may significantly reduce chances of multiple pregnancy by restricting to single embryo transfer.

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