I. Infertility treatment
The methods include rational dietary management to improve insulin refusal, pharmacological ovulation promotion and surgical laparoscopic treatment and pregnancy assistance techniques.
(i) Dietary management: The focus is on reducing the carbohydrate/fat intake ratio to curb insulin refusal and reducing body weight to quell abnormal gonadotropin and androgen secretion (Pasquali 1986).
(B) Pharmacological ovulation promotion: Clomiphene citrate (CC) is the main drug, and other ovulation-promoting drugs are used as appropriate.
As an anti-estrogen, it can compete with endogenous estrogen for receptors at the hypothalamic-pituitary level, inhibit estrogen responsible for feedbacks, cause GnRH-GnH release, increase ovulation, and directly promote ovarian steroid hormone production (Kerin 1985).
Method: Oral CC50-200mg daily for 5 days starting on the fifth day of the menstrual cycle (or progesterone withdrawal bleeding), with the maximum daily dose not exceeding 250mg to avoid hyperstimulation syndrome (OHSS). The above treatment should be used for 3-6 cycles and monitored for ovulation and pregnancy rate.
2.Triamcinolone acetonide: It is suitable for those who have failed in CC treatment. Triamcinolone is also an anti-estrogen and can promote ovulation with the same mechanism of action as CC in a small dose and short course.
Method: 20-40mg/d on the second (or fifth) day of menstrual cycle (or progesterone withdrawal bleeding) for 5 days. The therapeutic effect is similar to that of CC.
3. CC-hCC: It is suitable for those who cannot promote ovulation by CC alone or combined with luteal insufficiency. That is, after completing CC50-200mg/d×5 treatment, hCG 5000-10000 units should be injected intramuscularly on the 15th day of menstrual cycle, or hCG should be injected intramuscularly on the next day when follicle development is monitored by ultrasound and follicle diameter is ≥18mm and serum E2 is ≥300-500pg/ml.
4. CC-Dexamethasone: For PCOS combined with hyperandrogenemia, i.e. elevated plasma testosterone and DHEAS. The method is dexamethasone 0.5mg/d, taken before bedtime, with 50% ovulation rate in this group.
5. hMG-Dexamethasone: It is indicated for those who are ineffective in CC treatment, hypogonadotrophic and hyperandrogenemic. Its ovulation rate is 81% and pregnancy rate is 75%.
6. hMG-hCC: For patients with ineffective CC treatment and hypogonadotrophic hypogonadism. hMG 75-150u/d is injected intramuscularly on the fifth day of menstrual cycle. hCG is injected intramuscularly at the right time after the follicles have reached maturity under ultrasound monitoring of follicular development and serum E2.
7. pure FSH-hCG: The purpose of pFSH is to reduce the adverse effects of high LH and hyperandrogenemia during follicular development and oocyte maturation, and to improve the LH/FSH ratio. Recent clinical data suggest that; the application of GnRHa desensitization in PCOS followed by replacement of hMG with pFSH does not significantly improve the success rate of IVF, so this group of treatment remains to be further observed.
GnRHa-hMg-hCG: The purpose of GnRHa is to promote pituitary desensitization, prevent premature mid-menstrual LH peak and premature luteinization of follicles, and suppress hyperandrogenemia. plasma androgens can be reduced to post-castration levels after 4 weeks of GnRHa treatment in PCOS, but it does not affect the secretion of adrenal-derived androgens. The pregnancy rate in this group after 3 cycles of GnRHa treatment decreased to post-castration levels without affecting adrenal-derived androgen production. The pregnancy rate in this group for 3 cycles of treatment was 77% higher than that of the hMG or HCG treatment group alone.
9, pulsed GnRHa therapy: for people with hypogonadotrophic gonadotropinemia, but no significant efficacy in patients with PCOS. LH and testosterone were seen to increase after the administration of this group, with an ovulation rate of 38% and a pregnancy rate of 8%.
(DaLe (1991) observed 44 cases treated with GnRHa-hMG to promote super folliculogenesis, with 18.8±9 to 19.3±6.1 eggs harvested during the cycle and a 33% pregnancy rate of embryo transfer. However, due to the CanCELED cycle rate of 24.13% (14/58) due to OHSS, the value of the assisted conception technique in the treatment of PCOS still needs to be studied in depth.
Surgical treatment
The treatment includes ovarian wedge resection and laparoscopic microsurgery.
(a) Ovarian wedge resection (OWR): The exact mechanism of OWR for PCOS is not well understood. There are two groups of literature reported that serum To, Adione, E1, E2 decreased significantly 3-4 days after OWR, after that LH decreased and FSH did not change, 2 weeks after surgery LH/FSH ratio returned to normal followed by follicular development and ovulation. 80% ovulation rate, 50% pregnancy rate, 41% postoperative adhesion rate (Buttram 1975). The new microsurgical technique and the new adhesive barrier method were applied. Postoperative adhesions can be effectively prevented.
(B) Laparoscopic ovarian treatment (Laparoscopic ovarian treatment): It is a new technique. It is a new technique that involves laparoscopic multiple punch biopsy resection (MPBR), ovarian cauterization and laser ovarian vaporization and laser wedging.