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Choosing the right treatment for the infertile patient with polycystic ovary syndrome

Amit Shah,Anil Gudi and Prof Roy Homburg

Polycystic ovary syndrome (PCOS) affects about 10% of the female population of fertile age. Of these, 75% will have difficulty conceiving without help. The problem is the absence or very infrequent ovulation which, of course, precludes the chance of pregnancy. We now have many alternative ways of restoring ovulation. Curiously, the overweight or frankly obese patients can restore regular ovulation by losing 5% or more of their body weight without using any medication. For those who fail to do this or for those with PCOS but a normal body weight, clomifene citrate has been the first line treatment for almost 50 years. It is capable of restoring ovulation in about 80% and about half of these will conceive within three cycles of treatment. It has the advantage of being given in tablet form for just five days and it is cheap. If a conception is not forthcoming the usual second line treatment is daily injections of follicle stimulating hormone (FSH) given very carefully in order to produce just one ovulation in the cycle. The advantage is that the pregnancy rate is high but the medication is expensive. We, mischievously, wondered what would happen if we skipped the clomifene treatment and used FSH as the first-line therapy. In a large international study involving more than 300 patients, we compared these two treatments as first line therapy. There were 39% live births using clomifene and 52% using FSH. Although FSH was clearly superior, we stressed that it is less convenient for patients and more expensive. However, now we have the figures, every practitioner can balance his judgement of what should be the first line treatment for these patients.

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