1. The Effect of PCOS Treatment on Ovarian Function
Zi-Jiang Chen M.D., Ph.D.
Center for Reproductive Medicine
Shandong， China
Jinan, China

2. PCOS infertility treatment1
Ovarian Functions and Influence Factors 2
PCOS infertility treatment 3
PCOS treatment on the ovarian function

3. Ovarian Functions Two main functions
Produce oocytes
ovulation
Synthesize and secrete steroids E2 P T
Follicle : basic functional unit.
Once recruitment –
one follicle maturation
more atresia

4. Ovary age Age No. of oocytes Significance
At birth (1～2)× Determination of follicular pool
Reproductive time ×105
Later in the 30s × Rapid decrease phase( Deterioration phase)
Up to Menopause
> Exhaustion of follicles End of female reproductive life

5. Influence Factors on Follicular Pool
1、 Genetic factors:
The size of follicular pool is determined at birth, and different among individuals
2、 Acquired factors:
Damage or disease decreases the follicular pool, as it may decrease the ovarian cortex or blood supply

6. PCOS infertility treatment1
Ovarian Functions and Influence Factors 2
PCOS infertility treatment 3
PCOS treatment on the ovarian function

7. Evaluation of pre-treatment
Comprehensive Evaluation:
Treatment history
of infertility
Ovarian
function
Female age
family history
Infertility
cause
and duration

8. PCOS infertility treatment
Life style modification
Drug
Surgery
Ovarian function?
ART

9. Treatment Strategy Treatment Strategy For PCOS For PCOS-----2
First line treatment
Life style:
Exercise, smoke and diet
Second line treatment
Medicine: CC, Letrozole, Gn…
Third line treatment
new technology:
laparoscope, IVF，IVM …

10. Ideal COH protocol Idealized COH protocols:
Simple, convenient, economic；
High quality oocytes；
Better acceptability of the endometrium；
Higher implantation rate of single embryo；
Avoid or reduce complication.

11. COH with mild stimulation
Limitation :
more canceled cycles
Lower pregnancy rate
Simple, low cost
Mainly used for
poor-responder ,
low-income patients

12. PCOS ovulation induction
anovulatary PCOS patient
Life style modification, body weight, smoking, etc.
Clomiphene ovulation stimulation
euglycemic agent
gonadotropin
LOP or …
IVF

13. Outcome of CC/LE for PCOS patients in our center
Group Age Duration BMI FSH(IU/L) MC3d
LE/HCG ± ± ± ±1.09
CC/HCG ± ± ± ±1.45
 cycles
Ovulation rate (%)
pregnancy
Rate per
cycle (%)
No. of mature
follicles
Em Thickness
on HCG day (cm)
E2 on HCG
day (pg/ml)
 58
 65.5*
 13.8
1.077±0.28*
0.89±0.13*
267.88±37.64*
 45
 46.7
 13.3
 1.733±0.59
 0.78±0.08
456.67±101.45

14. PCOS Surgical Treatment
Ovary function Evaluation
Pros and cons of variety
Surgical skills are critical
Laparoscopic
Ovarian drilling

15. Traditional Wedge resection
Flaws：
POF rate 20-80％
Pelvic adhesion rate 40-75％
Lead to irreversible infertility
Flaws：
Pelvic adhesion rate：19%–82%
Ovulation dysfunction due to cicatricle on the surface of ovary
Difficulty in control quality and depth of drilling
Laparoscopic ovarian drilling
13和14合并 15

16. Ultrasound-guided immature follicle aspiration
( IMFA) to treat severe PCOS
Schematic diagram for
ultrasound mini invasive surgery
a Ovary before puncture
b Reinspection two weeks after puncture a b

17. hMG ovulation treatment
Methods
PCOS（108 cases）
Preoperative use hMG
（37 cases）
No use hMG
（71 cases）
IMFA
2-3 cycles
No. of antrum follicles<10/ovary
hMG ovulation treatment

18. Ultrasound-guided immature follicle aspiration
( IMFA) to treat severe PCOS
I group
II group
age
27.9±3.6
28.9±2.4
Infertile years
3.1±1.5
2.9±1.7
Before
treatment
LH/FSH
2.5±0.2
2.1±0.6 T0
76.3±12.5
67.8±25.7
No. of antrum follicles
24.5±13.1
27.3±11.8
After
0.8±0.2*
1.2±0.6*
36.8±16.5*
41.4±12.5*
Mean No. of
antrum follicles
9.2±3.4*
8.9±2.7*
Mean Puncture times
2.38
2.56
Mean hMG doses (ampoule)
Per cycle
20.8±6.3
22.6±10.5
With OHSS cases 2
pregnancy rate ( cases (%) )
20（54.1%）
16（47.1%）

19. Advantages of ultrasound-guided immature follicle aspiration for PCOS infertility treatment：
Smaller lesion，safe , less pelvic adhesion
reduce OHSS risk by decreasing number of antral follicles directly,
No risk of POF
Improve metabolic and endocrine status of PCOS
patients
Shortage: temporarily, invasively

20. PCOS infertility treatment1
Ovarian Functions and Influence Factors 2
PCOS infertility treatment 3
PCOS treatment on the ovarian function

21. The safety issue of Clinical treatment for PCOS
The safety during ovulation induction
PCOS patients
The safety in ART
The safety of minimally invasive surgery
(LOD, Transvaginal Ultrasound puncturation)

22. Safety issues in ovulation induction
ovarian hyperstimulation syndrome
multiple pregnancy
ovulation induction and tumor
ovulation induction and ovarian functional lesion

23. Ovulation induction and ovarian cancer
3837 cases infertility patients for 7-18 years, shows that using CC for over 12 months, the onset risk of ovarian cancer and ovarian borderline tumor increased.
In patients with ovulation induction:
ovarian cancer elevated 2.8 folds, ovarian borderline tumor increased 4 folds
Rossing MA et al N Engl J Med Sep 22;331(12):771-6
Whittemore AS et al Am J Epidemiol Nov 15;136(10 .

24. Reports on ovarian tumor after ovulation induction
33 cases with epithelial cancer
16 cases with borderline tumour
15 cases with granular cell tumor
1 case with malignant teratoma
Average onset age is 30.3-year-old,which is 20 years earlier than normal onset age
Ali Mahdavi, et al. Farr Nezhat. 2006,85(4):
Franco C,et al Apr;52(4):103-9.

25. Ovulation stimulation and ovarian reserve
Can repeated stimulated ovulation influence ovarian reserve by excessive consumption of follicles? Can it influence normal menstrual cycle and even if cause premature menopause？ For PCOS patients，superovulation can only decrease Antral Follicle Numbers and ameliorate menstrual cycle for a short time, no influence on ovarian reserve function
Nikolaou D et al. Hum Reprod Apr;17(4):
de Boer EJ et al. Fertil Steril May;77(5):978-85

26. Ovulation stimulation and ovarian reserve
Repeated superovulation is non-physiological stimuli, over consumption of follicle may exceed physiological limit
So far, no strong evidence show a adverse influence on ovarian reserve
Mild stimulation schemes has been advocated
large sample studies are needed in the future

27. Welcome to Expo China Take home messages Minimum cost
Treat PCOS patients with
Minimum cost
Maximum efficiency
Never forget to treasure ovaries!