الفهرس 
(1) IntroductionOnly 14 pages are availabe for public view
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Abstract
In this review, we highlighted several aspects of lines of treatment of polycystic ovary syndrome whether fertility is desired or not. We found that there is a wide range of controversy especially for ovulation induction.also, treatment depends uponmany factors such as; age , body weight , if fertility is desired or not. However, the different lines of treatment of PCOS can be summarized as following:
(I) Lifestyle modification:
- A structured lifestyle modification programme (focusing predominantly on diet and exercise) to achieve weight loss should still be the first line treatment in obese women with or without PCOS, particularly when their body mass index (BMI) exceeds 28.
- Weight loss before infertility treatment improves ovulation rates in women with PCOS, but there are limited data that it improves fecundity or lowers pregnancy complications.
- The best diet and exercise regimens are unknown, but caloric restriction and increased physical activity are recommended.
(II) Management of anovulatory infertility:
First-line therapy:
Clomiphene citrate: - Clomiphene citrate remains the treatment of first choice for induction of ovulation in most anovulatory women with PCOS.
- Selection of patients for CC treatment should take into account body weight/BMI, female age, and the presence of other infertility factors.
- The starting dose of CC should be 50 mg/day (for 5 days), and the recommended maximum dose is 150 mg/day.
Second-line therapy:
(1) insulin-sensitizing drugs:
Metformin as a first-line therapy:
The combined approach of metformin plus CC is not better than CC or metformin monotherapy. On the other hand, the choice between CC and metformin as first-step treatment should be drawn considering also contingent circumstances because of the lack of clear evidence.
Metformin as a second-line therapy:
* Metformin plus CC:
In CC-resistant patients, agreed in demonstrating a significant benefit of metformin cotreatment (regarding ovulation rate and pregnancy rate), however, the use of metformin in improvement of reproductive outcomes or in reducing the risk of developing metabolic syndrome in women with PCOS appears to be limited.
* Metformin plus LOD:
There is no significant benefit in clinical pregnancy rate or live-birth rate for the metformin administration after LOD.
Metformin pretreatment:
Metformin pretreatment improves the efficacy of CC in PCOS patients with CC resistance.
Metformin in patients who receive gonadotropins:In patients who received gonadotropins as treatment for anovulation, metformin addition reduces the duration of gonadotropins administration and the doses of gonadotropins required, and increases the rate of mono-ovulations, reducing the risk of cancelled cycles.
Metformin administration in infertile PCOS patients scheduled for IVF cycles is useful to reduce the OHSS risk.
Decisions about continuing insulin sensitizers during pregnancy in women with glucose intolerance should be left to the obstetricians providing care and should be based on a careful evaluation of risks and benefits.
(2) Aromataze inhibitors:
- Still insufficient evidence is available to recommend letrozole for routine use in ovulation induction.
- Most of the published studies (both controlled and uncontrolled) suggest that larger randomized studies are necessary to confirm the effectiveness of letrozole as an ovulation inducing agent in CC resistant infertile women, to define more clearly the efficacy and safety of letrozole in human reproduction.
(3) Gonadotrophins:
The recommended starting dose of gonadotropin is 37.5–50.0 IU/day.
Small FSH dose increments of 50% of the initial or previous FSH dose are less likely to result in excessive stimulation.
The duration of gonadotropin therapy generally should not exceed six ovulatory cycles.
Low-dose FSH protocols are effective in achieving ovulation in women with PCOS, but further refinement is needed to better control the safety of these regimens.
Intense ovarian response monitoring is required to reduce complications and secure efficiency.
Strict cycle cancellation criteria should be agreed upon with the patient before therapy is started.
Preventing all multiple pregnancies and OHSS is not possible at this time.
(4) Laparoscopic ovarian drilling:
- Laparoscopic ovarian surgery can achieve unifollicular ovulation with no risk of OHSS or high-order multiples.
- Intensive monitoring of follicular development is not required after LOS.
- Laparoscopic ovarian surgery is an alternative to gonadotropin therapy for CC-resistant anovulatory PCOS.
- The risks of surgery are minimal and include the risks of laparoscopy, adhesion formation, and destruction of normal ovarian tissue.
Third-line therapy:
Assisted reproductive techniques:
- In vitro fertilization is a reasonable option because the number of multiple pregnancies can be kept to a minimum by transferring fewer embryos.
- The optimal stimulation protocol is still under debate.
- There is a need to perform further RCTs comparing FSH stimulation protocols with use of GnRH agonists versus GnRH antagonists.
- It is reassuring that in the published data the pregnancy rates in women with and without PCOS is similar. This observation suggests that implantation is not compromised in PCOS.
- The increase in the cycle cancellation rate in women with PCOS appears to be due to absent or limited ovarian response or due to increased OHSS.
- IVM has a number of clinical advantages by the avoidance of large doses of exogenous gonadotropins, most importantly by avoiding the risk of OHSS.
(III) Management of PCOS in adolescents:
(1) Treatment of menstrual irregularities:
- Combined oral contraceptives: including Co-cyprindiol (Dianette) {EE and cproterone acetate} and Yasmin® {EE and drospirone}.
- {COCs with metformin} is the best for management for menstrual irregularities in patients with PCOS.
(2) Treatment of cutaneous manifestations:
- Combined oral contraceptives, especially those containing 3rd generation progestines such as: desogestrel, gestodine, norgestimate and drospirone.
- Dianette is licensed for the treatment of sever acne (refractory to prolonged antibiotic treatment) and for treatment of moderate to sever hirsutism.
- Topical Eflornithine hydrochloride is used in in whom systemic treatment is ineffective, contraindicated, or inappropriate also, to treat facial hirsutism in women.
- Mild cases of acne can be treated topically.
- Mild hirsutism can be treated by cosmetic measures alone, while more sever cases needs cosmetic measures as an adjunctive therapy.