PCOS and IVF: when is IVF considered, how is the risk of overstimulation (OHSS) assessed, and what do the antagonist protocol and freeze-all mean?
When PCOS and IVF are considered together, two questions come to the fore: when to move on to IVF, and how to manage the risk of your ovaries responding strongly to stimulation. In PCOS, IVF is mostly considered when no result is obtained from ovulation induction with medicines, or when there is an additional cause. The main matter attended to in the IVF process is ovarian hyperstimulation syndrome (OHSS). The information below offers a general framework and does not replace a diagnosis or treatment recommendation specific to you.
If you have PCOS, is IVF needed directly?
According to guidelines on this subject, in PCOS, if no result is obtained even though ovulation has been achieved with oral medicines and injection treatments, IVF is preferred over waiting and monitoring. This recommendation is conditional and the data it rests on are not yet strong. That is, a diagnosis of PCOS alone does not mean IVF directly; most of the time simpler treatments that support ovulation are tried first.
Can the order of treatment change if there is another cause?
If there is an additional cause, such as a problem in your tubes or a marked male factor, IVF can be considered even without ovulation induction with medicines being tried. The additional causes are assessed with your doctor; if you have PCOS, your doctor determines which route will be followed by considering all the findings together.
Why is the risk of overstimulation assessed in PCOS?
In PCOS there may be many small follicles in the ovaries, and this structure is linked to a strong response to stimulation medicines. A strong response can increase the risk of OHSS. In OHSS the ovaries enlarge and fluid may collect in the abdominal cavity; the severe form may need treatment in hospital. PCOS, young age, low body weight and high AMH are counted among the factors linked to the risk of OHSS. Even so, a diagnosis of PCOS does not mean that everyone will have an excessive response.
Can the response of your ovaries be understood beforehand?
Current guidelines on this subject recommend the antral follicle count or the AMH measurement to predict a high or low response beforehand; this is a strong recommendation, but the data it rests on are still very limited. A prediction states a likelihood and does not say definitely what response will occur; for this reason, close monitoring with ultrasound and, when needed, hormone measurements is carried out during stimulation.
How is the medicine plan chosen according to the risk of excessive response?
If a strong response is predicted in PCOS, current guidelines on this subject put forward, as a strong recommendation, the antagonist type from the group of medicines that prevent early ovulation; but the data this recommendation rests on are still very limited. Keeping the starting plan lower is also recommended conditionally (probably). Because a diagnosis of PCOS does not by itself mean a high response, these choices depend on your risk assessment.
Why can the trigger medicine and the decision to freeze embryos change?
If the risk of OHSS is marked, the type of trigger medicine that brings about the maturation of the eggs can be changed. Current guidelines on this subject present, in this situation, giving an agonist-type trigger together with freezing all embryos as a strong recommendation; but the data it rests on are still very limited. On the other hand, current assessments do not recommend freezing all embryos as the usual practice for everyone; they state that its effect on live birth is uncertain and that it is useful in the risk of OHSS. That is, this option makes sense in a high risk of OHSS and does not apply to everyone with PCOS.
Fresh or frozen transfer?
The time of the transfer becomes clear after it is seen how the stimulation has proceeded and what the risk of OHSS is. In a strong response, the transfer can be left to a later date; if your response is limited, a transfer in the same cycle can also be considered.
Can your medicine plan change during treatment?
In PCOS, when the response is very strong, the risk of OHSS can increase; for this reason your doctor can adjust the medicine plan during stimulation according to the monitoring findings.
How certain is the benefit of the methods recommended for PCOS?
Most of the recommendations on IVF strategies in PCOS rest on data of low or very low certainty. The data are not of the same strength for every question specific to PCOS; for this reason there may be differences in practice between centres and between people. Current guidelines on this subject do not recommend the use of growth hormone in people with PCOS.
Frequently Asked Questions
What information should I take to the doctor before IVF in PCOS?
Taking your previous AMH and antral follicle count results, your response to ovulation treatments, the list of medicines you use and, if you have them, summaries of your previous stimulation cycles makes it easier to build the plan. These records are information your doctor will use in assessing the risk of excessive response.
When do OHSS symptoms start?
Symptoms can appear in the days after the trigger medicine; if a pregnancy occurs, they may start later too.
Are metformin or myo-inositol added to IVF?
Current guidelines on this subject probably do not recommend routinely adding metformin, or using myo-inositol, in people with PCOS when the antagonist protocol is used; this is a conditional recommendation. Whether they will be used for another purpose is decided by the doctor carrying out your treatment.
Does everyone with a diagnosis of PCOS start IVF treatment?
No. Most of the time, simpler treatments that support ovulation are tried first. If there is an additional cause, the order of treatment can be different.
If there is a problem in my tubes, can IVF be considered without trying ovulation treatment?
Yes. If there is an additional cause, such as a tubal problem or a marked male factor, IVF can be considered directly. The decision is made together with all your findings.
Does PCOS mean I will definitely have overstimulation?
No. PCOS can be linked to a strong response and the risk of OHSS; however, it does not mean that an excessive response will develop in everyone.
Do AMH and the follicle count show my response for certain?
No. They help to predict the likelihood of a high or low response. Your actual response is monitored during stimulation with ultrasound and, when needed, hormone measurements.
Is the antagonist protocol applied in the same way to everyone with PCOS?
No. When a strong response is predicted, the antagonist type is put forward; the data supporting the recommendation are very limited. The starting plan is determined according to your risk assessment.
If I have PCOS, is it essential to freeze all embryos?
No. Freezing can make sense in a high risk of OHSS; it is not recommended as the usual practice for everyone. Its effect on live birth is uncertain.
If there is a risk of overstimulation, can the trigger medicine be changed?
Yes. If the risk of OHSS is marked, the type of trigger can be changed. Using an agonist-type trigger together with freezing all embryos is recommended; the data this recommendation rests on are very limited.
Can my medicine plan be readjusted while treatment is going on?
Yes. Your doctor can adjust the medicine plan according to the monitoring findings and the response of your ovaries.
Should growth hormone be added to IVF because of PCOS?
No. Current guidelines do not recommend the use of growth hormone in people with PCOS.
Get Your Free Consultation
Fill out the form below and our team will contact you
