A 34 year old girl presents to the infertility clinic with her husband

A 34 year old girl presents to the infertility clinic with her husband. They have been trying to concieve for 3 years. Her BMI is 31. She has dark pigmentation on her neck and severe acne on her face. There is also thinning of hair. Multiple follicles were on her ovaries on ultrasound… What is the SINGLE most appropriate initial management to treat her infertility?

A. Weight loss
B. Clomifene Citrate
C. Laparoscopic ovarian drilling
D. Combined oral contraceptive pills
E. Spironolactone

The most likely diagnosis here is Polycystic ovarian syndrome (PCOS). Multiple follicles seen on ovaries during an ultrasound helps confirm this. The scenario of acne on her face points towards an excess of androgens (Hirsutism, alopecia, acne are all manifestations of hyperandrogenism). And not to mention that her initial complaint was infertility which is one of the diagnostic criterion for PCOS.

The dark pigmentation on her neck is called acanthosis nigricans which is characterised by brown to black hyperpigmentation of the skin found in body folds,such as the axilla, nape of the neck, groin is a marker of insulin resistance Weight loss is the most appropriate answer here as the question is asking for the INITIAL management. Clomifene citrate is an option but weight loss comes first. Usually we would advise them to lose weight while getting blood test done to confirm anovulation. Some clinicians would start them on metformin right away on their first visit. This is a debatable topic but since metformin was not given in the options, we can exclude that. Also, metformin are unlicensed for use in PCOS and women need to be counselled before initiating therapy. Because it is currently unlicensed for use in PCOS, PLAB is unlikely to ask this. Laparoscopic drilling is a treatment for infertility for PCOS but is not first line. COCP is a treatment for PCOS to regulate their irregular periods but it is not for treatment of infertility Spironolactone (an antiandrogen) is used by endocrinologist to help with the effects of hirsutism. But again, it will not help with infertility. Polycystic ovarian syndrome (PCOS) Polycystic ovary syndrome (PCOS) is a complex endocrine disorder with clinical features that include hirsutism and acne (due to excess androgens), oligomenorrhoea or amenorrhoea, and multiple cysts in the ovary.

Symptoms: • irregular periods or no periods at all • an increase in facial or body hair (hirsutism) • loss of hair on your head • being overweight, experiencing a rapid increase in weight or having difficulty losing weight • oily skin, acne • difficulty becoming pregnant (reduced fertility). Diagnosis → Rotterdam consensus criteria Two out of three of the following criteria being diagnostic of the condition:

  1. Ultrasound → polycystic ovaries (either 12 or more follicles or increased ovarian volume 2. oligo-ovulation or anovulation 3. clinical and/or biochemical signs of hyperandrogenism
    General management • Weight loss Management for menstrual irregularities • Weight loss • COCP or cyclical progestogen or levonorgestrel intrauterine system. Management of infertility • Weight loss → weight loss alone may achieve spontaneous ovulation • Clomifene Citrate • If clomifene citrate fails, add on metformin or gonadotrophins or Laparoscopic ovarian drilling

Note regarding metformin: • The RCOG published an opinion paper in 2008 and concluded that on current evidence metformin is not a first line treatment of choice in the management of PCOS • Metformin is however still used, either combined with clomifene or alone, particularly in patients who are obese