This is the case of a 26 year-old nulligravida with Polycystic Ovary Syndrome who developed severe Ovarian Hyperstimulation Syndrome (OHSS) during ovulation induction for Intrauterine Insemination (IUI). Three problems were encountered during treatment. The first was whether to convert a planned ovulation induction and IUI, that resulted in multiple follicular development, to an in vitro Fertilization - Intracytoplasmic Sperm Injection cycle. The second problem was determining what strategies are relevant in preventing OHSS in a woman at high risk for developing severe hyperstimulation. The third problem was why, when and how to employ abdominal paracentesis in the management of severe OHSS. Though the patient's course was turbulent, management was successful. She is now awaiting embryo transfer and, ultimately, motherhood.
Human ; Female ; Adult ; OVARIAN HYPERSTIMULATION SYNDROME ; POLYCYSTIC OVARY SYNDROME

OBJECTIVE

To determine the threshold value for anti-Müllerian hormone (AMH) in the diagnosis of polycystic ovarian syndrome (PCOS) in infertile Filipino women and to ascertain the correlation of AMH with age and body mass index of PCOS women.

A retrospective cross-sectional study was carried out on infertile Filipino women at the Center for Advanced Reproductive Medicine and Infertility from August 2015 to March 2020. The women were separated into the PCOS group and male factor infertility group. Serum AMH was analyzed with Access AMH chemiluminescent immunoassay by Beckman Coulter. The AMH threshold for the diagnosis of PCOS was computed using Youden’s index.

There were 585 women included in the study, 311 (53.16%) were diagnosed with PCOS by the Rotterdam criteria, while 274 (46.84%) were non PCOS women. Mean serum AMH for PCOS was 5.88 ± 3.37 (p < 0.01). A threshold value of serum AMH above 3.86 ng/ml was predictive of PCOS by Youden’s index with a sensitivity of 67.2%, specificity of 77.7%, and correct classification rate of 72.1%. There was a negative correlation of AMH level with increasing age in both PCOS and non – PCOS group but the PCOS group had a higher AMH level. There was no correlation noted with AMH and body mass index in both groups.

AMH levels were higher in the PCOS women compared to those without the diagnosis. AMH threshold level could support the diagnosis of PCOS in infertile Filipino women.

OBJECTIVES: To compare the effects of metformin and orlistat in terms of reduction in weight or BMI, and improvement of ovulation rates, endocrinologic and lipid profiles, and occurrence of adverse events among overweight or obese women diagnosed with PCOS.

SEARCH METHODS: We searched Medline, OVID, HERDIN, EMBASE, Cochrane Library and ClinicalTrials.gov for head to head clinical trials of metformin versus orlistat for the treatment of overweight and obese women with PCOS. We also contacted the pharmaceutical companies and did hand-searching to look for related studies.

SELECTION CRITERIA: Only randomized controlled trials comparing metformin and orlistat as treatment for overweight and obese PCOS women were included. Other inclusion criteria included: trial period of at least 3 months duration, participants, of any ethnicity, 18-40 years old, who are overweight or obese, and studies with or without non-pharmacologic interventions as part of the treatment regimen.

DATA COLLECTION AND ANALYSIS: Titles and abstracts identified through the search strategies were screened by two reviewers. Two authors extracted data on publication characteristics, inclusion and exclusion criteria, intervention and co-intervention, primary and secondary outcomes, and details of study design. Two authors assessed the quality and risk bias of each RCT based on random sequence generation, allocation concealment, blinding of participants, caregivers, and assessors, attrition bias, incomplete outcome data, selective reporting, and publication bias.

MAIN RESULTS: We included 5 RCTs (n=221). Overall, treatment effects of orlistat and metformin showed no significant difference in the following outcomes: ovulation rates (RR 0.78; 95% CI 0.41, 1.49), reduction of BMI (MD -0.47; 95%CI:-1.53,0.59), serum testosterone levels (MD -2.15;95% CI -9.64, 5.33), free androgen index MD 3.26; 95% CI -7.91, 14.43), homeostatic model assessment-insulin resistance (3.70; 95% CI -6.74, 14.15), fasting insulin (MD 7.86; 95% CI -3.09, 18.81), HDL-C (MD -1.19 ; 95% CI -4.78, 7.16) and triglycerides (MD -1.95; 95% CI -8.81, 4.90). Orlistat was significantly better than metformin in reducing total cholesterol (MD -6.60; 95% CI -10.79, -2.41), and LDL (MD -5.04; 95% CI -9.64, 5.33), free androgen index (MD 3.26; 95% CI -7.91, 14.43), homeostaic model assessment-insulin resistance (3.70; 95% CI -6.74, 14.15), fasting insulin (MD 7.86; 95% CI -3.09, 18.81), HDL-C (MD -1.19 ; 95% CI -4.78, 7.16) and triglycerides (MD -1.95; 95% CI -8.81, 4.90). Orlistat was significantly better than metformin in reducing total cholesterol (MD -6.60; 95% CI -10.79, -2.41), and LDL (MD -5.04); 95% CI  -9.99, -0.09), and had less adverse events (RR 0.37, 95% CI 0.14, 0.96).

AUTHORS' CONCLUSIONS: Metformin and Orlistat have similar effects on weight loss, ovulation rates, and endocrinologic profiles of obese women with PCOS. Orlistat is more effective than metformin in decreasing total cholesterol and LDL -C levels, and has less adverse events than metformin. Therefore, we may recommend orlistat to overweight or obese women with PCOS who also have dyslipidemia. However, caution is given to our interpretations since small sample size, low quality of RCTs, and wide confidence intervals of pooled estimates significantly influence interpretation and recommendations. RCTs with adequately powered study populations are recommended to confirm findings of this review.

Insulin resistance is a condition in which the cells of the body become resistant to the effects of insulin, that is, the normal response to a given amount of insulin is reduced. As a result, higher levels of insulin are needed in order for insulin to exert its effects. Polycystic Ovarian Syndrome (PCOS) is one of the metabolic syndromes that link insulin resistance with diabetes mellitus, hyperandrogenism, and ovulatory dysfunction. PCOS often has a menarcheal age of onset characterized by a failure to establish a regular pattern of menses. In the case presented, the patient has primary amenorrhea assoicated with the development of secondary sexual characteristics, acanthosis nigricans, and acromegaloid attributes. Evaluation of pituitary function revealed that the patient's amenorrhea is secondary to hypergonadotropic hypogonadism, particularly, ovarian insufficiency. This case provides a unique setting to relate the syndrome of insulin-mediated expression of an acromegaloid pnenotype with insulin-mediated pathogenic mecahnisms for ovarian failure to exist concurrently.
Human ; Female ; Adult ; PRIMARY OVARIAN INSUFFICIENCY ; ACANTHOSIS NIGRICANS ; HYPERANDROGENISM ; POLYCYSTIC OVARY SYNDROME

OBJECTIVE: To determine whether the somatostain analogue, octreotide, pretreatment before ovulation induction with human menopausal gonadotropin (hMG) affects ovarian response, and ovulation induction outcome in infertile patients with polycystic ovarian syndrome (PCOS) resistant to clomiphene citrate (CC) METHODS: From November 1998 to June 1999, 30 infertile patients with PCOS unresponsive to CC were randomly allocated either octreotide pretreatment (treatment group) (n = 15) or hMG alone (control group) (n = 15) groups. In the treatment group, 100 g of octreotide were administered daily for 7 days after progesterone injection for withdrawal bleeding, and then hMG was administered for ovulation induction. RESULTS: There were no differences in the total number of hMG ampules required and the duration of hMG administration between the two groups. The number of follicles of 10-14 mm diameter on the day of hCG injection was significantly less in the treatment group than that in the control group (4.3 +/- 2.5 vs. 9.6 +/- 4.4, p < 0.001). The serum estradiol (E2) level on the day of hCG injection was significantly lower in the treatment group, with 1579.2 +/- 421.0 pg/ml compared with 2120.3 +/- 512.7 pg/ml in the control group (p < 0.001). The hematocrit level on the day of hCG injection was also significantly lower in the treatment group than that in the control group (36.9 +/- 2.1% vs. 40.8 +/- 2.9%, p < 0.05). The incidence of severe ovarian hyperstimulation syndrome (OHSS) seemed to be lower in the treatment group, but the difference did not achieve significance (6.7% vs 20.0%). CONCLUSION: This study suggests that octreotide pretreatment before ovulation induction could improve hormonal milieu compared to hMG alone, and therefore may be effective in ovulation induction for patients with PCOS resistant to CC.
Clomiphene ; Estradiol ; Female ; Gonadotropins ; Hematocrit ; Hemorrhage ; Humans ; Incidence ; Octreotide ; Ovarian Hyperstimulation Syndrome ; Ovulation Induction* ; Ovulation* ; Polycystic Ovary Syndrome* ; Progesterone ; Somatostatin*

OBJECTIVE: The aim of this study is to determine the incidence, clinical predictors, clinical manifestations of severe ovarian hyperstimulation syndrome in a large group. METHODS: A retrospective analysis of all IVF-ET cycles was performed from January 2005 to October 2007. We analysed incidence of severe OHSS and clinical manifestation. We assessed transvaginal number of follicles on hCG, serum estradiol, numbers of oocytes as the predictive factors comparing severe OHSS group and control group. Chi-square test and Student's t-test were used. Pleural effusion group was assessed identically. RESULTS: 6,292 IVF-ET cycles were undertaken in which 133 cycles of severe OHSS was developed (incidence: 2.11%). Patients age, transvaginal number of follicles on hCG, serum estradiol, numbers of oocytes were high in severe OHSS group and lately developed OHSS patients were all pregnant. 43.6% of severe OHSS were diagnosed polycystic ovarian syndrome. Pleural effusion was develop in 28 patients (incidence : 0.45%) and there were no predictive factor of pleural efusion. CONCLUSIONS: The incidence of severe OHSS was 2.11%. The protocol of controlled ovarian hyperstimulation did not affect the incidence of severe OHSS. Transvaginal number of follicles on hCG, serum estradiol, numbers of oocytes, PCOS, pregnancy were meaningful risk factors. There were no predicting factor for the pleural effusion of severe OHSS.
Estradiol ; Female ; Humans ; Incidence ; Oocytes ; Ovarian Hyperstimulation Syndrome ; Pleural Effusion ; Polycystic Ovary Syndrome ; Pregnancy ; Retrospective Studies ; Risk Factors

OBJECTIVES: The aim of this study was to determine the relationship of ovarian volume (OV) to age, height, and weight in Korean young women with the polycystic ovary syndrome (PCOS) undergoing ultrasonography (US) and to investigate the relationship between ovarian follicle count and volume on US and serum hormone levels including the levels of the anti-Müllerian hormone (AMH) and gonadotropin. METHODS: A total of 272 Korean nulliparous women aged 15 to 39 years who were newly diagnosed with PCOS at a university hospital were included in this study. Evaluation of the ovaries and measurement of OVs in all cases were randomly performed by ultrasound. The OV and follicle number (FN) were obtained in all cases. RESULTS: In Korean women with PCOS, mean OV was 7.9 ± 3.6 cm3 (right) and 6.7 ± 3.1 cm3 (left). Mean FN in the PCOS group was 14.2 ± 4.6 (right) and 13.8 ± 4.3 (left). OV and ovarian FN were unrelated to patient weight, height and body mass index. The left ovarian FN was related to patient age. AMH levels ranged from 5.31 to 43.1 ng/mL and the mean level was 13.9 ± 7.2 ng/mL. Serum AMH was related to OV and FN, and serum total testosterone was related to FN in Korean women with PCOS. CONCLUSIONS: In Korean nulliparous women with PCOS, OV was smaller than that in other ethnic groups and the right OV was larger than the left OV. Ovarian FN, AMH, testosterone are good markers for the diagnosis of PCOS in Korean women.
Anti-Mullerian Hormone ; Body Mass Index ; Diagnosis ; Ethnic Groups ; Female ; Gonadotropins ; Humans ; Ovarian Follicle ; Ovary ; Polycystic Ovary Syndrome* ; Testosterone ; Ultrasonography

Anti-Müllerian hormone (AMH) is a member of the transforming growth factor (TGF)-beta superfamily and mainly expressed by the granulosa cells of ovarian follicles. In women AMH is only expressed in ovarian follicles and therefore can be used for the evaluation of the ovarian reserve function and the prediction of ovary ageing and ovarian response during in vitro fertilization (IVF) treatment. This article summarizes the clinical application of AMH, especially in evaluating ovarian reserve functions.
Anti-Mullerian Hormone ; blood ; Biomarkers ; blood ; Female ; Fertilization in Vitro ; Follicle Stimulating Hormone ; blood ; Humans ; Ovarian Follicle ; physiology ; Ovarian Hyperstimulation Syndrome ; prevention & control ; Ovary ; physiology ; Polycystic Ovary Syndrome ; blood

OBJECTIVE: This study aimed to determine the threshold of anti-Müllerian hormone (AMH) as predictor of follicular growth failure in polycystic ovary syndrome (PCOS) patients treated with clomiphene citrate (CC). METHODS: Fifty female subjects with PCOS were recruited and divided into two groups based on successful and unsuccessful follicular growth. Related variables such as age, infertility duration, cigarette smoking, use of Moslem hijab, sunlight exposure, fiber intake, body mass index, waist circumference, AMH level, 25-hydroxy vitamin D level, and growth of dominant follicles were obtained, assessed, and statistically analyzed. RESULTS: The AMH levels of patients with successful follicular growth were significantly lower (p=0.001) than those with unsuccessful follicular growth (6.10±3.52 vs. 10.43±4.78 ng/mL). A higher volume of fiber intake was also observed in the successful follicular growth group compared to unsuccessful follicular growth group (p=0.001). Our study found the probability of successful follicle growth was a function of AMH level and the amount of fiber intake, expressed as Y=–2.35+(–0.312×AMH level)+(0.464×fiber intake) (area under the curve, 0.88; 95% confidence interval, 0.79–0.98; p<0.001). CONCLUSION: The optimal threshold of AMH level in predicting the failure of follicle growth in patients with PCOS treated with CC was 8.58 ng/mL.
Body Mass Index ; Clomiphene* ; Female ; Humans ; Infertility ; Ovarian Follicle ; Polycystic Ovary Syndrome* ; Smoking ; Sunlight ; Vitamin D ; Waist Circumference

BACKGROUND/AIMS: Although increased serum anti-Müllerian hormone (AMH) level has been suggested to be a surrogate marker of polycystic ovarian morphology (PCOM), its association with polycystic ovary syndrome (PCOS) is controversial, and its diagnostic value has not been determined. We aimed to observe the relationship between the AMH level and PCOS phenotypes and to determine the optimal cutoff value of AMH for the diagnosis of PCOS in young Korean women. METHODS: We recruited 207 women with PCOS (120 with PCOM and 87 without PCOM) and 220 regular cycling women with normoandrogenemia (100 with PCOM and 120 without PCOM). Subjects underwent testing at a single outpatient visit. Serum AMH level was measured. RESULTS: Women with PCOS had higher serum AMH levels than did regular cycling women with normoandrogenemia (p < 0.05). Women with PCOM had higher serum AMH levels than women without PCOM, regardless of PCOS status (p < 0.05). The optimal AMH cutoff value for the diagnosis of PCOS was 10.0 ng/mL (71% sensitivity, 93% specificity). Serum AMH was an independent determinant of total testosterone after adjustment for age, body mass index, and the number of menses/year (β = 0.31, p < 0.01). An association between AMH and hyperandrogenism was only observed in women with PCOS, and it was independent of the presence of PCOM. CONCLUSION: The serum AMH level can be useful for the diagnosis of PCOS at any age less than 40 years, and the optimal cutoff value for the diagnosis of PCOS identified in this study of young Korean women was 10.0 ng/mL.
Anti-Mullerian Hormone ; Biomarkers ; Body Mass Index ; Diagnosis ; Female ; Humans ; Hyperandrogenism ; Outpatients ; Ovarian Cysts ; Phenotype ; Polycystic Ovary Syndrome* ; Testosterone