• In PCOS, many factors affect ovarian function i.e. being overweight, having hyperandrogenemia, and having an elevated serum concentration of LH can adversely affect fertility
  • In recent years, an increasing number of scholars have emphasized individualized management and treatment of this disease because of its uncertainty and heterogeneity
• This article talks about the recent development of updated treatment plans to help infertile patients with PCOS achieve better outcomes

1. Weight loss
   1. Obesity has adverse effect on conception and increases risk of miscarriage
   2. Excess body fat in PCOS patients can aggravate insulin resistance and its clinical consequences
      1. Tend to suffer from hyperandrogenism and absent/irregular ovulation
   3. Weight loss helps improve menstrual function, fertility, endocrine parameters and pregnancy outcomes
2. Lifestyle Modifications
   1. This should be a first-line treatment
   2. Includes diet and exercise modifications
   3. Caloric intake should be limited to 1200-1500 kcal/day and exercise for 30 min 5 days/week
3. Obesity Drugs and Bariatric Surgery
   1. If the patient is unwilling to make lifestyle changes or for those who are prediabetic/diabetic- can opt for Metformin
      1. Metformin used to treat obesity and hormonal and metabolic disorders in patients with PCOS
   2. Patients who have difficulty decreasing weight may benefit from bariatric surgery and it can help severe patients alleviate PCOS and its sx such as hirsutism and irregular menstruation

Following are Ovulation induction therapies that can be utilized in PCOS treatment:

1. Clomiphene citrate
   1. First line treatment for patients with irregular or absent ovulation
   2. In a study that was done, over 6 months following CC treatment, more than 73% women ovulated, 36% became pregnant, and 29% gave birth
   3. Approximately 75% of pregnancies after CC treatment occur in the first 3 cycles of treatment and a few occur after 6 cycles
2. Aromatase inhibitors
   1. Letrozole is a third-gen aromatase inhibitor that blocks the conversion of androgens to estrogens in the ovarian follicles, peripheral tissues, and the brain
   2. According to a meta-analysis, the use of letrozole as first-line ovulation induction therapy in patients with PCOS may result in approximately 50% higher live birth rates compared with that of CC
3. Gonadotropin therapy
   1. Second-line therapy for ovulation induction
   2. Because patients with PCOS are relatively younger and have higher numbers of antral follicles than other infertile women, treatment with gonadotropins increases the risk of adverse events, such as ovarian hyperstimulation syndrome and multiple pregnancies
4. Metformin
   1. Basic causes behind PCOS-related anovulation are hyperinsulinemia and insulin resistance
   2. Metformin helps lower insulin concentration without causing hypoglycemia
   3. Not as effective as clomiphene in pregnancy rate and live birth rate 
5. Laparoscopic ovary drilling
   1. AN alternative to gonadotropic therapy
   2. LOD surgery induces single follicle ovulation
   3. May be useful in patients who are resistant to CC and persistently hypersecrete LH
   4. Patients with lower body weight and higher basal LH concentrations have better outcomes
6. Assisted Reproductive Technology (ART) therapy
   1. If all treatments have failed in infertile patients with PCOS, ART is the third-line treatment
      1. Includes artificial IUI, IVF embryo transfer, in vitro maturation, and intracytoplasmic sperm injection