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How to best manage polycystic ovarian syndrome (PCOS)?

Q: I have been diagnosed with polycystic ovarian syndrome(PCOS) and am trying to conceive. I am taking treatment for the last 2 months - in the first month the doctor prescibed Clomiphene citrate and did not monitor ovulation. I did not conceive and got my periods - so she prescibed Letrozol and monitored my ovulation. She said the growth was fine - on 11th day it was 15 in size and 14 day it was 25 in size - my cycle is of 31 days. She told me to have intercourse on 14 and 15th day. The ultrasound was done again on the 17th day and she told me ovulation must have ocurred on the 16th day. During the ultrasound she realised I have PCOS. However, I neither conceived nor got my periods. What exactly happened? Can ultrasound confirm ovulation 100%? Is it possible not to get periods even after ovulation occurs? What are my chances of conceiving? She has now given me Regesterone to get my periods and then Clomiphene citrate and Metformin.

A:PCOS is the commonest condition which affects women. It is so common that it cannot logically be called a disease or a disorder. In fact it is not a disease but a very wide spectrum of conditions and one does not know what part of spectrum you fall in. Have you given nature a chance before starting the treatment? Please check whether you ovulate naturally before taking drugs like Clomiphene. No! ultrasound is not a fool proof method of detecting ovulation. In fact only 80 per cent of the time is ovulation detected on U/S in the best of hands. The best (cheaper and surer method of detecting ovulation) is a day 23/24 serum progesterone level (the day may vary according to the length of your menstrual cycle). If your cycle is irregular then you could combine an ultrasound monitoring to be done by vaginal probe with a day 22-24 serum progesterone level. Like everything else in medicine this is also not 100% but much more accurate and cheaper than an ultrasound tracking. Once you are taking Clomiphene or similar drugs, then ultrasound has to be done to exclude a hyperstimulation of the ovaries especially in the first few cycles as this can be life threatening. In short you need a day 22-24 progesterone level to see if you are ovulating or not on your own. If you are not, please take Clomiphene; if you are ovulating on your own, Clomiphene will not help even if you do have PCOS. Other measures like losing weight (if indeed you are overweight) will help. To confirm the diagnosis postmentrual ultrasound examination of the ovary should be done postmenstrually with a vaginal probe and many follicles forming a ring (more than 15 in each ovary) suggests PCOS. If you did ovulate you should get periods 14 days to 16 days after the ovulation for you should be pregnant. When you take Clomiphene you should be taking Metformin only after the follicles are more than 12 mm (about day 12) and for the rest of the cycle. If you are not taking Clomiphene you can take Metformin (you have not written whether your blood sugars are ok or if you are obese)? After ovulation also you have only a 40 % chance of conceiving in three cycles and about 60% in 6 to 12 cycles and if you still do not conceive despite regular ovulation for 9 months or even one year should you be even considering second line drugs. In fact these drugs are experimental and have not yet been approved by the American FDA (Federal drug authority) for use in PCOS for induction of ovulation and the long term affects, especially on theh offspring, are largely unknown.

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