Risk Reduction Strategies for Assisted Conception in Women with Polycystic Ovary Syndrome

Superovulation in assisted conception can create Ovarian Hyperstimulation Syndrome (OHSS). Morbidity and even mortality that can occur with OHSS should be avoided by using the lowest risk and safest treatment strategy. Women with Polycystic Ovary Syndrome (PCOS) are at high risk of over response due to the ample number of antral follicles capable of responding to stimulation. Diagnosis of PCOS is based on a collection of subjective symptoms, signs and laboratory investigations. Anti-Mullerian Hormone (AMH), produced by the granulosa cells of the antral follicles, is elevated in women with PCOS. In a consecutive series of women presenting to an infertility clinic, the finding of increased AMH in those with PCOS was confirmed. Furthermore, AMH was shown to correlate with anovulation and hyperandrogenism. A single AMH value is interchangeable with any of the Rotterdam diagnostic criteria. Proposed values are 29pmol/L for polycystic ovarian morphology and 45pmol/L for either anovulation or hyperandrogenism using the generation II assay. Metformin has been shown to reduce the risk of OHSS in an agonist IVF cycle. The antagonist cycle is recommended for those at high risk of over-response. In a randomised double-blinded placebo controlled trial on 153 recruited patients; metformin was shown to have no effect on the incidence of OHSS in an antagonist cycle. There was no improvement in clinical pregnancy or live birth rate. The trial highlighted the discrepancy in clinical outcome between a White Caucasian and South Asian population. Avoidance of superovulation is an attractive option offered by in vitro maturation (IVM). A pilot study of 30 IVM cycles proved that immature oocytes can mature and fertilise in vitro at similar published rates. Unfortunately, no clinical pregnancies were created despite adequate transferred embryo quality. Although no incidence of OHSS, IVM appears to have been superseded by alternative approaches with replicable higher pregnancy rates.