Q1 What are polycystic ovaries? A1. Polycystic ovaries are ovaries in which there are more than the usual number of small cystic structures that contain eggs, otherwise commonly known as follicles. It is normal for there to be several follicles that are developing each month in a woman’s ovaries. In women with polycystic ovaries there are more than the usual number, and usually more than 20 in each ovary. Polycystic ovaries are detected by ultrasound which can be performed either with a probe in the vagina or a probe on the lower part of the abdomen.
2 Q2 What is polycystic ovary syndrome? A2. Polycystic ovary syndrome (PCOS) is a common condition in which women with polycystic ovaries also have other symptoms usually of irregular or absent menstrual cycles and also signs of excess androgen hormones leading to unwanted hair growth on the face and body, sometimes acne and occasionally thinning of the hair on the head. Women with polycystic ovaries often have an imbalance of the natural hormones that are produced by the ovaries with an excess of the androgen hormone testosterone, which is a naturally occurring hormone in all ovaries. Some women with PCOS have a tendency to gain weight in which case there is a concurrent elevation of insulin levels which has additional metabolic effects. Women with polycystic ovaries also have high levels of anti‐Müllerian hormone (AMH) as this correlates with the number of small follicles.
3 Q3 Can I have polycystic ovaries without polycystic ovary syndrome? A3. Approximately 20–25% of women have polycystic ovaries as detected by ultrasound scan; of these, three quarters have symptoms consistent with polycystic ovary syndrome. Therefore, it is possible to have polycystic ovaries without any symptoms of the syndrome. Symptoms can sometimes develop over time particularly in those who gain weight.
4 Q4 What are the implications of having polycystic ovaries if I am due to have IVF treatment? A4. Women with polycystic ovaries have a tendency to respond excessively to the drugs that are used to stimulate the ovaries and therefore there is an increased risk of ovarian hyperstimulation syndrome (OHSS). For this reason, a low dose of the stimulation drugs is used in a protocol that is designed to minimize the risk. However, if ovarian hyperstimulation does occur the treatment cycle is either discontinued or alternatively the eggs can be collected and fertilized and then the resultant embryos frozen for future use but not transferred in a fresh cycle. This enables the ovaries to settle down, minimizes the risks and also increases the chance of having a pregnancy.
5 Q5 Is IVF the only treatment for PCOS? A5. If you are wishing to get pregnant and have polycystic ovary syndrome it is important first to optimize your heath, body weight and nutritional status. If you are having irregular periods and therefore not ovulating regularly, we usually advocate the use of medication to stimulate ovulation, which has to be monitored carefully by ultrasound. It is only if this treatment doesn’t work that IVF might be considered as an option. IVF is sometimes required for women with PCOS or polycystic ovaries alone, if there are other fertility problems such as damaged or blocked fallopian tubes.
References
1 1 The Rotterdam ESHRE/ASRM‐sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long‐term health risks related to polycystic ovary syndrome (PCOS). Authors: Fauser B, Tarlatzis B, Chang J, Azziz R, Legro R, Dewailly D, Franks S, Balen AH, Bouchard P, Dahlgren E, Devoto, Diamanti E, Dunaif A, Filicori M, Homburg R, Ibanez L, Laven J, Magoffin D, Nestler J, Norman R, Pasquali R, Pugeat M, Strauss J, Tan SL, Taylor A, Wild R, Wild S. Human Reproduction 2004; 19: 41–47.
2 2 Teede HJ, Misso ML, Costello MF, Dokras A, Laven J, Misso ML, Moran L, Piltonen T, Norman RJ on behalf of the International PCOS Network. Recommendations from the international evidence‐based guideline for the assessment and management of polycystic ovary syndrome. Simultaneous publication: Fertility and Sterility, 2018; 110:364–379; Clinical Endocrinology, 2018; 89: 251–268; Human Reproduction, 2018; 33:1602–1618.
3 3 Balen AH, Morley LC, Misso M, Franks S, Legro RS, Wijeyaratne CN, Stener‐Victorin E, Norman RJ, Fauser BJCM, Teede H. WHO recommendations for The Management of Anovulatory Infertility in Women with Polycystic Ovary Syndrome (PCOS), Human Reproduction Update 2016; 22: 687–708 doi: 10.1093/humupd/dmw 025.
4 4 Mourad S, Brown J, Farquhar C. Interventions for the prevention of OHSS in ART cycles: an overview of Cochrane reviews. Cochrane Database Syst Rev. 2017 Jan 23; 1:CD012103. doi: 10.1002/14651858.CD012103.pub2.
5 5 Sha T, Wang X, Cheng W, Yan Y.A meta‐analysis of pregnancy‐related outcomes and complications in women with polycystic ovary syndrome undergoing IVF. Reprod Biomed Online. 2019 Aug; 39(2):281–293. doi: 10.1016/j.rbmo.2019.03.203. Epub 2019 Mar 29.
6 6 van Wely, M., et al., Recombinant versus urinary gonadotrophin for ovarian stimulation in assisted reproductive technology cycles. Cochrane Database Syst Rev. 2011;( 2): CD005354.
7 7 Tso LO, Costello MF, Albuquerque LET, Andriolo RB, Macedo CR. Metformin treatment before and during IVF or ICSI in women with polycystic ovary syndrome. Cochrane Database Syst Rev. 2014;CD006105.
8 8 Al‐Inany HG, Youssef MA, Ayeleke R, Brown J, Lam W, Broekmans FJ. Gonadotrophin‐releasing hormone antagonists for assisted reproductive technology. Cochrane Database of Syst Rev. 2016, Issue 4. Art. No.: CD001750. DOI:10.1002/14651858.CD001750.pub4
9 9 Youssef MAFM, Van der Veen F, Al‐Inany HG, Mochtar MH, Griesinger G, Nagi Mohesen M, et al. Gonadotropin‐releasing hormone agonist versus HCG for oocyte triggering in antagonist‐assisted reproductive technology. Cochrane Database Syst Rev. 2014;CD008046.
10 10 Haahr T, Roque M, Esteves SC, Humaidan P. GnRH Agonist Trigger and LH Activity Luteal Phase Support versus hCG Trigger and Conventional Luteal Phase Support in Fresh Embryo Transfer IVF/ICSI Cycles‐A Systematic PRISMA Review and Meta‐analysis. Front Endocrinol (Lausanne). 2017; 8:116.
11 11 Devroey P, Polyzos NP, Blockeel C. An OHSS‐Free Clinic by segmentation of IVF treatment. Hum Reprod. 2011; 26:2593–7.
12 12 Chen Z‐J, Shi Y, Sun Y, Zhang B, Liang X, Cao Y, et al. Fresh versus Frozen Embryos for Infertility in the Polycystic Ovary Syndrome. N Engl J Med. 2016; 375:523–33.
13 13 Abbara A, Jayasena CN, Christopoulos G, Narayanaswamy S, Izzi‐Engbeaya C, Nijher GMK, et al. Efficacy of Kisspeptin‐54 to Trigger Oocyte Maturation in Women at High Risk of Ovarian Hyperstimulation Syndrome (OHSS) During in vitro Fertilization (IVF) Therapy. J Clin Endocrinol Metab. 2015; 100:3322–31.
14 14 Siristatidis CS, Maheshwari A, Vaidakis D, Bhattacharya S. in vitro maturation in subfertile women with polycystic ovarian syndrome undergoing assisted reproduction. Cochrane Database Syst Rev. 2018 Nov 15; 11:CD006606. doi: 10.1002/14651858.CD006606.pub4.
15 15 Mourad S, Brown J, Farquhar C. Interventions for the prevention of OHSS in ART cycles: an overview of Cochrane reviews. Cochrane Database Syst Rev. 2017 Jan 23; 1:CD012103. doi: 10.1002/14651858.CD012103.pub2.
16 The renal transplant patient
Justin Chu and Lynne Robinson
Birmingham Women’s Hospital, Birmingham, UK
Case History 1: A 30‐year‐old woman with unexplained infertility is scheduled to undergo IVF treatment. She has a background history of renal transplant for IgA nephropathy. She takes mycophenolate mofetil, prednisolone, enalapril and cephalexin.
Case history 2: A 24‐year‐old woman plans to undergo a second cycle of ICSI treatment for male factor infertility. She is a kidney transplant recipient who developed OHSS in her previous ICSI cycle.
Background
Women with chronic kidney disease have disrupted hypothalamus‐pituitary‐ovarian axis function leading to deranged menstrual cycles, anovulation and therefore reduced fertility [1]. When chronic kidney disease reaches end‐stage, prolactin is raised (due to reduced renal clearance) and there are often low LH and FSH levels due to lack of pulsatile gonadotropin releasing hormone release