This document provides information about Dr. Laxmi Shrikhande's credentials and experience in gynecology and fertility. It then summarizes guidelines for assessing and managing polycystic ovary syndrome (PCOS) and infertility. Key recommendations include using letrozole as first-line pharmacological treatment for infertility in PCOS patients, and considering gonadotropins as second-line if letrozole fails. The risks of ovarian hyperstimulation syndrome are also discussed for PCOS patients undergoing fertility treatments like IVF.

1. Dr. LaxmiShrikhande
MD;FICOG;FICMU
Director-Shrikhande Fertility Clinic, Nagpur
President Menopause Society, Nagpur
National Corresponding Editor-The Journal of Obstetrics & Gynecology of India
Senior Vice President FOGSI 2012
Vice Chairperson Indian College OB /GY
Governing Council member ICOG 2012-2017
Governing Council Member ISAR 2014-2019
Governing Council Member IAGE for 3 terms
Patron-Vidarbha Chapter ISOPARB
Chairperson-HIV/AIDS Committee, FOGSI (2007-09)
Received Best Committee Award of FOGSI
Received Bharat excellence Award for women’s health
President Nagpur OB/GY Society 2005-06
Associate member of RCOG
Member of European Society of Human Reproduction
Visited 96 FOGSI Societies as invited faculty
Delivered 6 orations and 296 guest lectures
Publications-Thirteen National & seven International
Presented Papers in FIGO, AICOG, SAFOG, AICC-RCOG conferences
Conducted adolescent health programme for more than 15,000 adolescent girls

2. PCOS & Infertility
DR LAXMI SHRIKHANDE
DIRECTOR-SHRIKHANDE FERTILITY CLINIC,
NAGPUR

3. PCOS is one condition where people always like
to agree to disagree.
Over the years these disagreements have
continued.
The criteria for diagnosis keep on changing.
Management guidelines keep on changing

4. Latest Guidelines 2018
International evidence-based guideline for the
assessment and management of polycystic ovary
syndrome 2018
By ESHRE &ASRM
Released in July 2018 during ESHRE congress at Barcelona

5. Assessment and treatment of infertility
1st line non-pharmacological management for infertility Lifestyle interventions
1st line pharmacological management for infertility
Letrozole
(consider
Letrozole as 1st
line therapy)
Clomiphene
citrate
Clomiphene citrate
+ metformin
Metformin
Gonadotrophins
2nd line pharmacological/surgical management
Gonadotrophins Laparoscopic ovarian surgery
3rd line management could be other appropriate interventions including IVF

6. Management
Life style interventyions
Behavioural strategies
Dietary intervention
Exercise intervention
Obesity and weight assessment

7. Ovulation induction principles
Pregnancy should be excluded prior to ovulation induction.
Unsuccessful, prolonged use of ovulation induction agents should be
avoided, due to poor success rates.

8. OVULATION INDUCTION
FIRST LINE
Letrozole – aromatase inhibitor
Start with 2.5-5 mg from day2,3,4 for 5 days
Follicular monitoring from day 8 onward
Advantages over CC
◦ No anti estrogenic effect on endometrium and cervical mucus
◦ Limited number of mature follicles
◦ Reduced OHSS and multiple pregnancy

9. OVULATION INDUCTION
FIRST LINE
Clomiphene citrate – selective estrogen receptor modulator
◦ Start on day 2,3,4 or 5 of period
◦ Start with dose of 50 mg for 5 days
◦ Maximum dose 150-200 mg
◦ Follicular monitoring from day 8
◦ HCG for trigger
◦ Establish ovulatory dose and continue for 3-6 cycles.

10. OVULATION INDUCTION
SECONDARY LINE
Gonadotropins –
◦ CC / letrozole resistance
◦ CC/Letrozole failure
◦ Persistant hypersecreation of LH
◦ IUI or IVF

11. Which Gonadotrophins in Non IVF cycles
HMG
Highly Purified HMG
Urinary FSH
Highly Purified FSH
Recombinant FSH

12. Non IVF Gonadotrophin cycles – what should be the starting dose
◦ Age.
◦ Antral Follicle count.
◦ AMH
◦ Previous response.

13. Total Cycle Monitoring
Ovarian Cycle
Uterine Cycle

14. Trigger-when ?
HCG at 18-20 mm (CC+Gn cycles)
HCG at 20-22 mm (CC cycles)
Dose- 5000 -10,000 IU

15. Don’t forget
the
Luteal Phase !!!!

16. LPS
Is there any need for support in natural cycle / IUI / IVF cycles ?
What to give ?
When to give ?
What dose?
 When to stop ?

17. PCO drilling
A surgical solution for a medical problem ?
Reduces hyperandrogenism and improves the intraovarian
millieu
Lacks standardization in terms of indications, modality,
follow up
Best if < 3 years infertility, thin and high LH

18. In-vitro fertilisation (IVF)
Women with PCOS undergoing IVF ± ICSI therapy should be counselled prior to starting
treatment, including on:
 availability, cost and convenience
 increased risk of ovarian hyperstimulation syndrome
options to reduce the risk of ovarian hyperstimulation

19. O H S S
“Abundance,
like want,
ruins many”.
~ Romanian Proverb ~

20. Patterns of OHSS
Early OHSS,
◦ generally presents 3–7 days after hCG administration
◦ acute effect of ovulatory hCG, and it can occur in patients who do not become
pregnant.
Late OHSS
◦ presenting 12–17 days after hCG.
◦ late OHSS is induced by endogenous hCG from the trophoblast of the implanting
pregnancy.
◦ Wheelan JG 3rd, Vlahos NF. Fertil Steril 2000; 73:883–896.

21. Maternal PCOS in pregnancy
Increased prevalence of:
Early pregnancy loss
Gestational diabetes
Pregnancy induced hypertension
SGA babies

22. PCOS - Late sequelae
Hyperinsulinemia / hyperandrogenism / obesity
•Diabetes mellitus x7
•Hypertension x4
•Low HDL/high LDL

23. Summary-Fertility Treatment
Letrozole is first-line pharmacological infertility therapy; with
clomiphene and metformin having a role alone and in combination.
In women with PCOS and anovulatory infertility, gonadotrophins
are second line but can be first line also.
In the absence of an absolute indication for IVF, women with PCOS
and anovulatory infertility, could be offered IVF third line where
other ovulation induction therapies have failed.

24. Dr. Laxmi Shrikhande
Shrikhande Fertility Clinic
Ph-8805577600 / 8805677600
shrikhandedrlaxmi@gmail.com