Chapter 28: Infertility Issues and Polycystic Ovary Syndrome

INTRODUCTION

Polycystic ovary syndrome is one of the most common endocrinopathies in women during reproductive years. It is a complex disease process that leads to ovulatory dysfunction, infertility, irregular uterine bleeding, and various skin manifestations. The skin manifestations include hirsutism, oily skin, acneiform eruptions, and skin pigmentation known as achanthosis nigricans.¹

There are certain manifestations of the polycystic ovary syndrome that also affect the health of women; one of these is obesity, which is present in about 30%–50% of patients with polycystic ovary syndrome. This will predispose women to what is known as metabolic syndrome. This metabolic syndrome includes prediabetes, diabetes, and hypertension.² Furthermore, there is the possibility for these patients to develop endometrial cancer if they are not treated properly.

The etiology of polycystic ovary syndrome is not known, but it may be due to some genetic predisposition. Polycystic ovary syndrome is reported to be present in 50% of sisters and 40% of mothers of patients with this disease process. The mode of inheritance is suggested to be autosomal or X-linked process. Aneuploides and polyploides of the X chromosome have been described. Deletion of the long arm of chromosome 11 was seen in some cases of polycystic ovary syndrome. The genes related to steroidogenesis and carbohydrate metabolism are suggested to be factors in the development of this syndrome.^3,4

HISTORICAL ASPECTS AND DIAGNOSTIC CHARACTERISTICS

Polycystic ovary syndrome was first described in 1935 by Irving Stein and Michael Leventhal.⁵ These two gynecologists from Chicago described a category of women with enlarged ovaries, irregular cycles, and infertility. The ovaries contained multiple cysts, which are follicles that have not ovulated. They treated these women with wedge resection of the ovaries; the women resumed ovulatory cycles, and some of them achieved pregnancy.⁶ Stein-Leventhal syndrome remained the characteristic identification of this disease because of these two scientists and their contribution. Wedge resection was the main line of treatment in these patients until the late 1970s. At that time, endocrine science was not advanced, and hormonal assays, as we know today, were not present or available. Therefore, the Stein-Leventhal syndrome was a purely clinical and morphological diagnosis. In the mid-1970s, it became possible, due to the development of proper hormonal assays, to evaluate patients’ gonadal hormones. Several societies developed criteria based on endocrine testing to rule out other diseases.

Diagnostic criteria were put forward by several societies and institutions. In the early 1990s, the National Institutes of Health (NIH) had a consensus meeting; afterward, certain criteria were published as diagnostic for patients with polycystic ovary syndrome⁷:

1. Anovulation, manifested by oligomenorrhea or amenorrhea

2. Excess androgen activity, manifested by hyperandogenemia or hypoandrogenism

Patients who fulfilled these two criteria would be diagnosed as having polycystic ovary syndrome.

In 2003, representatives of the American Society of Reproductive ...