Can I have a child with PCOS?

November 27, 2006

Dear Dr Mitchell,
I am 30 years old and have been diagnosed with PCOS. I have tried the Metformin but it made me really ill so my doctor had to stop me from that medication. I take Allese birth control and it allows me to have a regular monthly period but I notice that as soon as I stop taking the pills my period does not come at all. My real concern is having a child. I perceive that to be a difficult task, but what is the true possibility?

Polycystic Ovary Syndrome is the presence of irregular, scanty periods or total absence of the menstrual periods with clinical evidence of an excess of male hormones (androgens). This may be in the form of excessive hair growth on the face, chest or abdomen in association with acne.

There is usually excessive weight gain. It is the most common cause of failure to ovulate and accounts for 70 per cent of cases. In all patients with suspected Polycystic Ovarian disease, enlargement or hyperplasia of the adrenal gland or a tumour that secretes androgen should be ruled out.
Polycystic Ovary Syndrome is prevalent in approximately five per cent of women of the reproductive age. The level of testosterone in the blood is usually elevated and this causes the excessive hair growth and the acne.

If infertility is not desired, then the use of a low dose oral contraceptive pill will usually work well in establishing good cycle control. However, when the pill is discontinued, then the period will resume its usual irregular pattern. In women with Polycystic Ovary Syndrome, there are several modalities of treatment available to induce ovulation. This includes weight loss, clomiphene, clomiphene plus metformin, clomiphene plus glucocontroid, gonadotrophin injections, ovarian surgery and invitro fertilisation with embryo transfer.

If you are overweight then it is recommended that you should lose at least 10 per cent of your body weight. A body mass index greater than 27 is associated with an increased risk of infertility as a result of failure to ovulate. Weight loss reduces the level of testosterone in the blood and results in a decrease in the blood insulin levels. Women with Polycystic Ovary Syndrome tend to have a high level of insulin and a greater tendency towards becoming diabetic.

Studies done in women who have polycystic ovaries show that there is a two fold to five fold increased risk of diabetes. Women with polycystic ovaries because of the associated obesity and diabetic tendency are at increased risk for heart disease. The weight loss is best achieved by a combination of diet and exercise. However, exercise at levels greater than one hour per day has been associated with an increase in infertility due to failure to ovulate, so exercise should be done in moderation.

In a woman with polycystic ovaries who does not want to conceive, the oral contraceptive pills provide good cycle control. The oral contraceptive pills are also associated with a significant reduction in the risk for cancer of the uterus. Both depo provera and oral progesterone tablets may be used for cycle control but there is a great tendency towards breakthrough bleeding which may be undesirable.

In women attempting to conceive, 80 per cent will ovulate in response to clomiphene treatment and 50 per cent of these women will conceive. A half of all women using clomiphene will conceive with taking a 50mg tablet daily for five days as a starting dose and another 20 per cent will do so on two tablets daily for five days.

Most pregnancies will occur within the first six cycles once ovulation is established. Increased body weight is associated with a greater need for a larger dose of the clomiphene tablet and a greater likelihood of failure to conceive. If ovulation fails to occur with clomiphene then other drugs may be used. This includes metformin and the more expensive gonadotrophins. The gonadotrophin therapy is associated with a high risk of multiple pregnancies and more side effects.

Metformin improves the frequency of ovulation in women with polycystic ovaries. It may be used on its own or in conjunction with clomiphene or gonadotrophin therapy. Symptoms such as diarrrhoea, nausea, vomiting, abdominal bloating, flatulence and loss of appetite with anorexia in some cases are the most common side effects. These may be reduced by starting with a low dose initially, and then gradually increasing the dose or by using a slow release preparation that is now available. Metformin is not known to cause any birth defects and is safe in pregnancy.

You should consult your gynaecologist who will probably suggest that you start a lower dose of metformin in conjunction with a trial of clomiphene. A regular exercise programme, not exceeding one hour per day with an appropriate diet to lose some weight, if you are overweight will also be of great benefit. If conception does not take place then an x-ray to rule out blocked tubes (Hysterosalpingogram - HSG) should be done.

Your partner should also do a semen analysis if all your tests show that your tubes are not blocked and you ovulate on clomiphene and metformin. If you do not conceive then you should ask to be referred to the Fertility Unit at the University Hospital of the West Indies for invitro fertilisation (IVF).

Dr Sharmaine Mitchell is an obstetrician and gynaecologist. Send questions and comments via email to allwoman@jamaicaobserver.com or fax to 968-2025. We regret that we cannot supply personal answers.

Source: http://www.jamaicaobserver.com/magazines/AllWoman/html/20061126T190000-0500_115844_OBS_CAN_I_HAVE_A_CHILD_WITH_PCOS__.asp