Brief Answer:
Possibility of PCOS

Detailed Answer:
Dear xxxxxxxxxxxxxxxxxxx,

I have understood your concern.

Before answering your questions, let me opine on the problem of your wife. From the description you have provided, your wife seems to have Polycystic Ovarian Syndrome (PCOS) in which multiple follicles in the ovaries mature but the egg release does not take place.

The classic features of this condition are delayed menstruation, round face, increased abdominal fat, coarse hair on the legs and sometimes on the abdomen. If not treated in time hair may appear on face and breast also. Dandruff and itching over skin also is found in many cases. Many a times this condition is precipitated by stress. Obesity, over eating, lack of exercise also are precipitating factors.

Now let me answer your questions one by one:

1. & 2. This does not happen suddenly. It is a gradual process. However, stress of changed atmosphere, culture and people after marriage may precipitate the condition. She may be having irregularities in the menstruation previously. These follicles contain the immature eggs. They are maturing every month; however, every cycle only one egg gets released. In your wife's case, many follicles have matured but none has released eggs. This condition is called as PCOS. This is hyperinsulinimia, hyperandrogenism (hormonal) and metabolic problem. Is she overweight? What is her BMI? Is she having more fat at the waist? What is her waist:hip ratio? Does she have coarse hair on legs or hair on lips? This is not a dangerous condition; however needs active management.

3&4. She will have to have active management of the condition so that her eggs start getting released and she becomes pregnant. She has to have exercises to bring down the fat around the waist. High protein, low fat and low carbohydrate diet plays a very crucial role in this condition. Some medicines like Inositol, NAC and L-arginine are claimed to help. So the management of this condition is medicinal plus life-style modification.

I feel your doctor has diagnosed the case well in time. Please report to the Gynaecologist for the active management of PCOS. She should get rid of it with proper treatment and conceive.

Meanwhile, I would like to have her following reports:
1. Blood examination for FSH, LH, Oestrogen & Progesterone. After seeing these reports, I may ask for some more.
2. Ultrasonography of the abdomen - detailed report of ovaries and uterine lining.

I suppose I have given you the preliminary information based on whatever history and clinical findings you have provided. After you furnish with the other information I have asked for and the images and reports suggested, I may be better equipped to discuss the case further.

If you feel you want to have some more information, I am always available for you, xxxxxxxxxxx.

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Brief Answer:
Managing PCOS at different levels

Detailed Answer:
Dear xxxxxxxxxxxxxxxxxxxxxxx,

If she is having PCOS, it is very unlikely that she will have her ovulation naturally. Your doctor has given her Sysron N tablets which contains noerthisterone which is a Progestetional medicine. This medicine with bring her menses. After her menses are induced, she will be probably given some medicines like Clomiphene citrate or so to induce ovulation. Then the ovulation is monitored by ultrasonography to locate the day of egg release (ovulation). This helps her to conceive.

However, I feel this is the treatment is aimed at only to help her become pregnant. Clomiphene citrate has better results in achieving the ovulation, however the success in achieving fruitful pregnancy is lesser. Still this is a very good first line of treatment.

PCOS as I explained you is now explored thoroughly and has proved to be not only a condition restricted to the ovaries but is understood to be a hormonal and metabolic disorder. If you recall, I had mentioned that this is a condition of hyperinsulinism, hyperandrogenism and anovulation.

Early symptoms of PCOS are Few or no menstrual cycles, Heavy irregular vaginal bleeding, Hair loss, Acne and oily skin and Depression or mood swings. Gradual symptoms include Weight gain, Repeated miscarriages (if conception takes place), infertility, Hyperinsulinaemia and sleep disturbances. Now we believe in treating the patient not only for egg release but comprehensively to tackle insulin insensitivity, effects of increased male hormone, etc. These patients have increased susceptibility for diabetes mellitus, cardiomyopathy, atherosclerotic changes, fat imbalance, etc.

Of course, initially, diagnosis of PCOS has to be confirmed. Once diagnosed, addressing all the factors for prevention is necessary for healthy life. I referred to his modality of management as active management of PCOS. Induction of egg release and achieving pregnancy is only one aspect of it. Life-style modification including eating habits, diet pattern, exercises, etc. plays a major role in this.

First get the condition confirmed to be PCOS before addressing any line of management. Had you replied to my questions, I would could have clear picture of the case to guide you further.

If you want any more information, you may ask me. If you are happy with the information so far shred with you, you may post a review with 5 starts rating for me.

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Brief Answer:
Comprehensive treatment

Detailed Answer:
Dear xxxxxxxxxxxxxxxxxxxxx,

I have explained you the varied aspects of PCOS. When I mean active treatment, it refers to following aspects:
1. Covering all the aspects
2. Not ignoring any part and delaying it for future by concentrating only on conception.
3. Getting all the investigations performed.

Active treatment is my own term I have used. For simplicity, I may change it to 'comprehensive treatment'.

I had asked you the reports and images of certain investigations. Without viewing them, it will not be possible for any doctor to predict any guess about conception. After viewing the reports, I may ask for some more reports if required. As it is, response to treatment, particularly in hormonal imbalances depends up on individual body response and cannot be predicted in time frame, unlike the body response to antibiotics in infections or painkillers in physical pain. The doses and schedules of the hormonal medicines may have to be adjusted. Moreover, if one regime fails, one has to switch over to the other regime. So please try to understand the modality of the treatment and the limitations and variations of medical science. No one can predict the period for conception even in normal couple. Give your Gynaecologist fair time with full faith.

Unless the underlying causes are ascertained, no definitive line of treatment can be planned. So please subject both of you for the required investigations for correct line of treatment.

The process in managing a case of infertility is:

1. Evaluation of male factor by Semen examination.
2. To find out the status of egg release (ovulation) in female: by Ultrasonography ovulation monitoring, study of the uterine lining and hormonal assays as I have suggested you.
3. To look for the patency of the female genital tract, in particular tubes: by Hysterosalpingography and Laparoscopy.
4. Any other factor if located needs to be investigated further.

Please cooperate with your Gynaecologist for complete 'comprehensive' work up.

And as far as management of her PCOS in concerned, I repeat, go for 'comprehensive' investigations and management instead of concentrating only on conception, though induction of ovulation would be the first and main aim.

I hope, I have given you precise guidelines. For any more information, I m available for you, dear xxxxxxxxxxxxxxxxxxxxxxx.

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