Fertility Cure

Pregnancy Miracle Program

Lisa Olson developed Pregnancy Miracle which is based on clinically proven, natural and holistic method of getting pregnant no matter if you are in your 30s or 40s or having Tubal Obstruction, High Level of FSH, Uterine Fibroids or any other infertility causes. This is the exact 5-step process Lisa used to get pregnant twice at age 43 and 45 after battling infertility for more than a decade and being told by her doctors she would never have kids of her own. It is Continually Updated, Lisa learn new things every single day from continued research, testing and experimentation. She also get a lot of ideas as to how she can improve Pregnancy Miracle from the women that she counsel. She is therefore constantly in the process of refining and perfecting Pregnancy Miracle. More here...

Pregnancy Miracle Overview

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Before You Become Pregnant

As you plan your pregnancy, you and husband should both be aware that it will be more expensive for you than for women without diabetes. You will need special care during pregnancy and special precautions during delivery, and your child may require special attention at birth. Choose your medical team before you become pregnant. Your obstetrician, pediatrician, diabetologist, and diabetes educator will work together to provide you with the best care and advice. They will help you choose a hospital that has the latest monitoring and testing equipment and a high-risk nursery. Statistics indicate that 5-7 of babies born to women with insulin dependent diabetes have abnormalities. The good news is that, with excellent blood sugar control prior to and during the first three months of pregnancy, the risk of abnormalities is reduced to that of women without diabetes 2-3 . Your level of control can be measured by blood glucose monitoring records and by a blood test called a glycosylated...

Pathogenesis Of Infertility

Serum luteinizing hormone (LH) levels are elevated in many patients with PCOS, especially in those who are lean (7). Abnormal regulation of LH was previously implicated as the cause of chronic anovulation in patients with PCOS. Studies have shown that increased LH levels during the follicular phase in patients with PCOS have deleterious effects on conception rates (8) and may contribute to higher miscarriage rates (9) although the mechanism remains controversial. However, up to 50 of women with clinical and biochemical manifestations of PCOS have normal LH levels, rendering its measurement of limited diagnostic value (3). Hyperinsulinemia is present in about 80 of obese women with PCOS and 30-40 of normal weight women with PCOS (10). Disturbances of insulin secretion or action are more prominent in women with PCOS complicated by amenorrhea or anovulation than in equally hyperandrogenemic women with regular cycles (11, 12). Hyperinsulinemic insulin resistance plays a key role in the...

Getting a few tests if youre thinking of getting pregnant

If you're a woman with T1DM thinking of becoming pregnant, you must undergo several tests before and during your pregnancy to ensure that you don't develop or worsen diabetic complications and that your baby is healthy at birth and stays healthy afterwards (see Chapter 7 for more about these tests). They include

Infertility Treatment In Pcos

Been used to stimulate FSH more recently, aromatase inhibitors have been investigated for this purpose. Laparoscopic ovarian drilling (LOD), gonadotrophin releasing hormone (GnRH) agonists and GnRH antagonists work through reducing LH concentrations and are second- or third-line agents for the treatment of infertility.

ICSI Health Care Guideline

The information contained in this ICSI Health Care Guideline is intended primarily for health professionals and the following expert audiences This ICSI Health Care Guideline should not be construed as medical advice or medical opinion related to any specific facts or circumstances. If you are not one of the expert audiences listed above you are urged to consult a health care professional regarding your own situation and any specific medical questions you may have. In addition, you should seek assistance from a health care professional in interpreting this ICSI Health Care Guideline and applying it in your individual case. This ICSI Health Care Guideline is designed to assist clinicians by providing an analytical framework for the evaluation and treatment of patients, and is not intended either to replace a clinician's judgment or to establish a protocol for all patients with a particular condition. An ICSI Health Care Guideline rarely will establish the only approach to a problem....

Abnormalities of menstrual cycle and infertility

PCOS is the commonest cause (78 per cent) of anovulatory in infertility (Hull, 1987). It was demonstrated that menstrual abnormalities are more frequent in obese than non-obese PCOS women (Kiddy et al., 1990). In addition, it was shown that a reduced incidence of pregnancy and inadequate response to pharmacological treatments to induce ovulation may be more common in obese PCOS women (Galtier-Dereure et al., 1997). Insulin resistance and accompanying hyperinsulinaemia, which can increase amount of body fat, can be directly related to impaired ovulation in obese PCOS women since treatment with insulin-sensitizing agents leads to improvement of menstrual cycles. It has been found that obese PCOS women tend to have lower ovulation response to pulsatile GhRH analogue administration than non-obese counterparts (Filicori et al., 1994). In the recent studies of PCOS women conceiving after in vitro fertilization or intracytoplasmic sperm injection, it was observed that those with obesity had...

Infertility

An ominous sign in any species, infertility is not just another disease or problem. you can't. Remember to kill bacteria and viruses too, especially Gardnerella, Neisseria, Treponema, the ancient enemies of human reproduction. Be extra careful with contraception during the dental cleanup. You could get pregnant the very next day This is no joke. It is a serious hazard to conceive a child while mercury is loose and rampant in your body from the removal process. It may be a higher risk than leaving it untouched. If you are pregnant no dentist will want to finish the job of mercury removal Don't try to get pregnant yet. You may have tried fertility pills, in vitro fertilization, and other methods for getting pregnant over a ten year time period, all to no avail. Then you start cleaning up your body and taking your mercury out and suddenly you are pregnant before the job is complete It may seem unreasonable and illogical to have to be careful after ten years of no worries, but play it...

Monitoring your glucose and ketones

Your appropriate amount of weight gain depends upon your weight at the time you become pregnant. Your BMI determines your weight gain. You need to determine your BMI (see Chapter 3 if you're not sure how to do this calculation). If your BMI is normal, you should gain 20 to 25 pounds during the pregnancy. However, if you're overweight, you need to gain less weight through the pregnancy, 15 to 20 pounds. If you're obese, you should gain no more than 17 or 18 pounds. And if you're underweight, you may gain 25 to 30 pounds.

Kelsey ES Salley and John E Nestler

Pathogenesis of Infertility Infertility Treatment in PCOS Polycystic ovary syndrome (PCOS) affects 5-10 of women of reproductive age. One of the hallmarks of the syndrome is chronic oligo- or anovulation, making it one of the most common causes of infertility. While infertile PCOS patients have traditionally undergone conventional fertility treatments, insulin-sensitizing agents are also being explored because of the hyperinsulinemic insulin resistance intrinsic to the syndrome. Once women with PCOS become pregnant they are at increased risk for complications including early pregnancy loss, gestational diabetes and pregnancy-induced hypertension. Because pregnancy is a state of heightened insulin resistance and compensatory hyperinsulinemia, insulin-sensitizing agents, particularly metformin, are being investigated for prevention of these complications. Key words Polycystic ovary syndrome Fertility Pregnancy Infertility Early pregnancy loss Gestational diabetes Pregnancy-induced...

Using contraception until youre under control

Until you achieve control of your T1DM and are officially ready to conceive (meaning that your doctor has given you the go-ahead), the wisest course of action is to use contraception. For purposes of contraception, the first day of your menstrual cycle is the first day of bleeding between the 8th and 18th days, you're most fertile and likely to become pregnant if you have unprotected sex, so contraception is absolutely crucial during this time. You're most fertile for 24 hours before ovulation and a few hours after ovulation. You can determine ovulation by taking your body temperature. When it rises 0.2 degrees F and persists at that level, ovulation has occurred. If it rises again a few days later and persists, conception has likely occurred.

Being careful with conception

Antirejection drugs have been associated with reduced fertility in women. If they do get pregnant, they have more complications of pregnancy than women who don't take these drugs. They may have more infections, high blood pressure, swelling, and even loss of the transplanted organ. For these reasons, it's suggested that women who want to become pregnant after transplantation of the kidney and or pancreas wait at least one year until their condition stabilizes. There aren't sufficient studies of pregnancy in women who have undergone islet transplantation, but common sense suggests that waiting a year for stabilization of the transplant is a good idea.

Should a woman with Type DM be counselled regarding future pregnancies and why

The diabetic woman who wants to become pregnant should know that pregnancy can have detrimental effects on already existent microvascular diabetic complications, can cause hypoglycaemia or ketoacidosis, hypertension or aggravation of preexistent hypertension, polyhydramnios, premature birth or be complicated by acute pyelonephritis or other infections.

Once You Are Pregnant

In the first trimester, targets are designed to help you minimize the risk of birth defects or miscarriage. In the second and third trimesters, the targets will help to prevent your baby from growing too large. If you have trouble staying in the range, or if you have frequent or severe hypoglycemia, talk to your health care team about revising your treatment plan or your targets. Food and Exercise. Your eating habits may need to change during pregnancy to help you stay on target. And you also will want to make sure that you are eating foods that provide adequate nutrition for you and your baby. You will probably have a visit with your dietitian even before you become pregnant. In general, choose nutritious foods that are part of any healthy eating plan (see Chapter 8). Women with gestational diabetes may be able to manage their blood glucose levels more effectively by limiting their carbohydrate intake to 35 to 40 percent of calories.

Diabetic Retinopathy in Pregnancy

Pregnancy and parity do not appear to increase the risk for development of diabetic nephropathy nor do they increase the progression of established diabetic nephropathy (94). Rossing et al. have reported an observational study of 93 diabetic women who were followed over a range of 3-28 years during which 26 of the women became pregnant after developing nephropathy (95). The study demonstrated that pregnancy did not have any long-term effect on renal function or survival, comparing the pregnant diabetic women with those women who did not become pregnant (95). Other studies have demonstrated that among pregnant women with decreased renal function due to either diabetic or nondiabetic causes, there is an increased risk of end-stage renal disease within months to a few years after delivery (96, 97). Although the rates of maternal complications are increased when moderate or severe renal insufficiency is present among pregnant diabetic women, the fetal survival rate remains high (97)....

Striving for a Healthy Pregnancy

If you have diabetes and want to become pregnant, you need to confer with an expert in pregnancy and diabetes before you conceive. In the following sections, I explain potential complications you may experience and some steps you should take to ensure the healthiest pregnancy possible.

Identifying Polycystic Ovarian Syndrome

In fact, women with PCOS who do get pregnant have a prevalence of gestational diabetes that is 2 to 3 times that of those women without PCOS. The major health risks for someone with PCOS, besides infertility, are the occurrence of impaired glucose tolerance and type 2 diabetes, as well as ges-tational diabetes. In addition, just like patients with the metabolic syndrome (see Chapter 5), these women are at greater risk for high blood pressure, abnormal blood fats, and cardiovascular disease. Other than oral contraceptives, any treatment that is successful for reducing the acne, hairiness, and decreased insulin sensitivity in PCOS also makes the woman much more liable to get pregnant. If she doesn't want to become pregnant, she and her partner need to take the necessary precautions.

Having Gestational Diabetes

If you're pregnant (yes, that excludes you men) and you've never had diabetes before, during your pregnancy you could acquire a form of diabetes called gestational diabetes. If you already have diabetes when you become pregnant, that is called pregestational diabetes. As I discuss in Chapter 6, the difference between pregestational diabetes and gestational diabetes is very important in terms of the consequences for both mother and baby. Gestational diabetes occurs in about 2 percent of all pregnancies.

Longterm Complications

Prevalence of retinopathy at 8-10 years after the onset of diabetes in more recent reports varies between 30 and 60 . This is lower than may be expected from older cohort studies. Data support the conclusion that this may be attributed to better levels of glycemic control that are achieved during the last decades (24). It was already known from previous intervention studies that the development and progression of diabetic retinopathy in T1D can be prevented by better glycemic control (25). An important observation from these trials is that retinopathy may actually worsen during the first year of tightened glycemic control. This observation is even more relevant with respect to women planning to become pregnant this usually calls for intensified insulin treatment in order to achieve adequate glycemic control before conception. Although the risk of progression during pregnancy is increased in women with the highest initial HbAlc values and in those with the greatest reduction in HbAlc...

Diabetic Nephropathy And Pregnancy

The potential problems of diabetic nephropathy (DN) and pregnancy require the anticipation of preconception care. Clinicians who care for adolescent and adult diabetic women need to recognize that they may become pregnant, that most of the risks to mother and offspring are related to poor control of hyperglycemia and hypertension, and that the risks may be reduced through intensified multifactorial interventions before conception and throughout pregnancy.

Howard Blank and Jennifer Wyckoff

Established preexisting diabetes affects over 1 of pregnancies, and that number is expected to rise. Hyperglycemia during the first few weeks of pregnancy can result in congenital malformations or miscarriage. Preexisting diabetes increases the risk of developing both fetal and maternal complications in pregnancy some of which can be devastating. Through careful attention to contraception, preconception counseling and preconception medical care, many of these complications can be avoided. Preconception care (PCC) programs have been shown to be efficacious at reducing complications and perinatal mortality as well as cost effective. Wider adoption of PCC programs is needed. Key words Diabetes Pregnancy Women Preconception Congenital malformations Miscarriage

Gonadotropin Releasing Hormone

Both GnRH agonists and antagonists are being investigated for their roles in ovulation induction in patients with PCOS. While GnRH agonists in conjunction with gonadotropins may increase pregnancy rates, reduce the risk of miscarriage, and may be of use in patients with high LH levels who have either failed gonadotropin therapy alone or who have had recurrent miscarriages, the concern for multiple follicle development has hampered their use in these patients (6, 107, 108). Only small studies have been completed using GnRH antagonist treatment in conjunction with gonadotropins in patients with PCOS, and randomized controlled trials are needed to further define their role (109). Finally, pulsatile GnRH treatment has also been explored but due to the small size and short duration of studies, it needs further investigation (110).

Counseling And Selecting A Method

A woman's reproductive desires and contraceptive preferences change throughout her reproductive life, irrespective of whether she has diabetes. Thus, the discussion of pregnancy plans and contraceptive preferences needs to be ongoing. A woman with diabetes should be encouraged that with preparation, good medical and prenatal care, most likely she will be able to have a successful pregnancy and reduce her risk to have an anomalous or premature baby. Importantly, she must know the positive steps she can make to prepare for pregnancy or to keep healthy until she desires pregnancy. While it is important for her provider to explain to her the increased risk of congenital anomalies, miscarriage, and morbidity, it is more productive to harness her motivation by helping her set reachable health and glycemic goals to reduce these risks. The more she takes charge of her general and diabetic health, the safer any pregnancy, planned or unplanned, will be for her and her baby (see Chap. 15).

My sister with diabetes had a baby and it nearly killed her Its just not a safe thing to do

Women with diabetes can and do have healthy babies all the time. It doesn't cost them their lives or health, either. The survival rate for pregnancy is no different between women with and without diabetes, as long as the woman with diabetes takes care to practice tight blood glucose management and treats any diabetes complications before becoming pregnant. And chances are excellent that her baby will be just as healthy as a baby born to a mother without diabetes. But there are risks. High glucose levels early in pregnancy may cause miscarriage or improperly formed organs in the baby. High glucose levels later in the pregnancy put the mother at risk for hypertension and preterm labor as well as possible worsening of any diabetes complications. High blood glucose levels later in pregnancy can cause the baby to grow too large and cause problems with delivery. Mother's Health. Before becoming pregnant, you need a thorough physical exam. Any problems that could jeopardize your health or...

Pregnancy and Gestational Diabetes

If you have diabetes, it's important to plan your pregnancy. Your blood glucose levels need to be as close to normal as possible before you get pregnant. Too much glucose in the blood in the first 2 months of pregnancy, while the baby is developing its nervous system, limbs, and organs, can cause birth defects. It also increases your risk of miscarriage. It's important to take care of your general health, too. Pregnant women with diabetes are more likely to develop high blood pressure, hypoglycemia, and a temporary worsening in the complications of diabetes, including retinopathy, if their blood glucose levels are not closely managed. Blood glucose goals for you are likely to be even lower than for people who are not pregnant. Tight pre-meal blood glucose levels for you may be 70 to 110 mg dl. Ideal after-meal blood glucose levels might be less than 130 mg dl.

In Vitro Fertilization

IVF represents a last resort for PCOS patients with infertility. A meta-analysis examining IVF outcomes in patients with PCOS compared with normal controls found an increased cycle cancellation rate and lower fertilization rates among patients with PCOS (111). However, they were also found to have more oocytes per retrieval and comparable pregnancy and live birth rates when compared with the control group. In vitro maturation of oocytes in which immature oocytes are retrieved without stimulation is being investigated for its utility in PCOS patients who have failed other treatments or couples who have additional causes of infertility. Studies so far have shown similar pregnancy, live birth and miscarriage rates to IVF, and the technique reduces the risk of OHSS compared with traditional IVF cycles (112-114).

Diabetes and pregnancy

Uncontrolled diabetes may cause fetal loss as a result of early spontaneous miscarriage. The congenital malformation rate of 4-10 remains three to five times greater than that in the general population with malformations involving the heart and central nervous system being potentially lethal. Diabetic malformations are likely to be caused by both genetic and environmental factors with glucose being the most likely

First Trimester Weeks

The first trimester HbA1c is used to counsel patients about the risks of miscarriage and congenital birth defects. Higher HbAlc levels are associated with higher risks of birth defects. The pathophysi-ology of this association is not known. There are likely many variables in the pathway for embryopathy that may be synergistic with or resulting from hyperglycemia including disruption of regulatory genes (Pax3 that controls embryo development), oxidative stress interrupting prostaglandin metabolism, inhibition of somatomedin activity, deficiency in myoinosotol, accumulation of sorbitol, ketonuria, and other genes responsible for cell proliferation as well as apoptosis (11-18). Table 3 lists the associated percentages of major and minor fetal malformations based on the HbA1c. The summary of all the studies shows that HgAlc's in the moderate range standard deviation (SD) from the mean < + 7 pose barely elevated risks of congenital anomalies over the baseline risk in the general...

Where to Go from Here

Where you go from here depends on your needs. If you want a basic understanding of what T1DM is and isn't, head to Part I. If you or someone you know has a complication due to T1DM, skip to Part II. For help in treating T1DM using every available tool, turn to Part III. If you're thinking of becoming pregnant, are going into menopause, are elderly, or have a parent with T1DM, Part IV is your next stop. Likewise, go there if you want to know what your options are for school, work, and other activities, or if you want to know how to manage travel or illness. For a bird's-eye view of getting kids involved, key treatment strategies, the mythology that surrounds T1DM, and the latest discoveries, check Part V.

The pros and cons of a kidney transplant

The biggest advantage of having a kidney transplant is that your quality of life is much improved compared to dialysis. For one thing, you no longer need dialysis if it has been started. For another, you're likely to be able to resume your regular life activities, even becoming pregnant if you're female. (I explain the precautions for women with T1DM to take when they're trying to conceive in Chapter 16.)

Relationship to Insulin Resistance and Diabetes

Although the exact mechanisms that lead to the development of PCOS are not clear it has been shown that insulin resistance and compensatory hyperinsulinemia possess the central role in the pathophysiology of the syndrome. Women with PCOS have both basal and glucose-stimulated hyperinsulinemia compared with weight-matched women and the high levels of insulin are thought to mediate the development of hyperandrogenemia, anovulation, and infertility. At the same time, insulin resistance and compensatory hyperinsulinemia are responsible for the cardiovascular risk factors. The hyperinsulin-ism correlates with the hyperandrogenism and occurs independent of obesity (180,181).

Isoflavones and coronary heart disease

The oestrogenicity of isoflavones was first documented over 50 years ago, when isoflavones present in the diet of sheep were found to be responsible for the permanent infertility induced in these animals. Subsequent epidemiological evidence in humans suggested that high soy consumption, the main dietary source of isoflavones, was cardioprotective, in part attributed to the ability of the isoflavones in soy to act as oestrogen mimics. Demonstration of the ability of soy products to bring about a beneficial change in the blood lipoprotein profile led the US Food and Drug Administration (FDA, 1999) to approve a claim that '25g of soy protein a day, as part of a diet low in saturated fat and cholesterol, may reduce the risk of heart disease'. It is currently uncertain whether soy isoflavones contribute to the cholesterol-lowering effects that are reported in controlled trials of soy and soy products. Recent studies have shown small hydrolysed soy peptides that may enter the circulation...

Maternal Complications

Women with type 1 diabetes mellitus have a relatively high risk of developing diabetic complications before pregnancy because the onset of the disease occurred at a young age (18). Complications include retinopathy, nephropathy, hypertension, impaired thyroid function, neuropathy, and atherosclerosis, in rare cases. In addition, hyperglycemia in the mother may lead to maternal complications, such as polyhydram-nios, urinary tract infections, candidal vaginitis, recurrent spontaneous abortions, and infertility. Because these concomitant diseases affect growth and development of the fetus, it is all the more important to treat and control them. They can be minimized and prevented by tight glycemic control, maintaining HbAlc measurements under 5 in pregnant women. HbAlc values are generally lower in pregnancy because of active hemopoiesis and hemodilution from an expanded blood volume.

Definition of the syndrome

Polycystic ovary syndrome (PCOS) is a commonly diagnosed female endo-crinopathy and it is the commonest cause of anovulatory infertility affecting 1-5 per cent of women in the reproductive age group. It is considered to be a syndrome not a disease that manifests with heterogeneous clinical features. The most common features of PCOS are irregular menstrual cycles (oligomenorrhea or amenorrhoea), signs of androgen excess (hirsutism, acne, alopecia), and often obesity. However, only 5-10 per cent of women with PCOS express all the typical clinical features of the syndrome (Balen, 1999 Franks, 1999). At present the diagnosis of PCOS is usually based on the criteria derived from 1990 NIH-NICHHD (National Institutes of Health-National Institutes of Child Health and Human Development) conference, which are ovulatory dysfunction, clinical evidence of hyperandrogenism and or hyperandrogenaemia and exclusion of related disorders such as congenital adrenal hyperplasia, hyperprolactinaemia, or...

Reproductive Function

Preconceptional consultation may reveal abnormalities in reproductive function. Women with DM may report delay in menarche, delay in ovulation, and increased incidence of menstrual irregularities (7-9). Individually or collectively, these may contribute to relative infertility.

Only Two Health Problems

No matter how long and confusing is the list of symptoms a person has, from chronic fatigue to infertility to mental problems, I am sure to find only two things wrong they have in them pollutants and or parasites. I never find lack of exercise, vitamin deficiencies, hormone levels or anything else to be a primary causative factor. So the solution to good health is obvious

Insulin Resistance in PCOS

Insulin resistance in women with PCOS appears even more common than in the general population (79, 83). It should, however, be emphasized that the majority of the studies have simply demonstrated that, in comparison to adequate control groups, insulin resistance, as measured by various techniques or methods, was more common in subjects with PCOS. There are no epidemiological studies focusing on the prevalence of insulin resistance in PCOS. In one study examining the characteristics of more than 1,000 consecutive women with androgen excess, Azziz et al. (84) found that 716 of them had PCOS and were characterized, as a group, by hyperinsulinemia and insulin resistance. Interestingly, 60 of them were obese, which indicates that obesity per se may be an amplifier of a cause of this metabolic derangement. Many other studies have in fact reported that insulin resistance is very common in the presence of obesity, particularly the abdominal phenotype (79-81). The common thought is that...

Disclosure of Potential Conflict of Interest

In the interest of full disclosure, ICSI has adopted the policy of revealing relationships work group members have with companies that sell products or services that are relevant to this guideline topic. The reader should not assume that these financial interests will have an adverse impact on the content of the guideline, but they are noted here to fully inform readers. Readers of the guideline may assume that only work group members listed below have potential conflicts of interest to disclose. ICSI's conflict of interest policy and procedures are available for review on ICSI's website at http www.icsi.org.

Recommended Resources

The websites were viewed by the ICSI Management of Type 2 Diabetes Mellitus guideline work group as credible resources. ICSI does not have the authority to monitor the content of these sites. Any health-related information offered from these sites should not be interpreted as giving a diagnosis or treatment.

Diagnostic Testing for Diabetes or Prediabetes Impaired Glucose Tolerance [IGT or Impaired Fasting Glucose [IFG

Patients presenting with symptoms of diabetes should be tested. Possible screening tests for these conditions include a fasting plasma glucose or an oral glucose tolerance test. Testing patients with hypertension, dyslipidemia, and heart disease is also recommended. Other patients at risk for diabetes are also appropriate for testing (American Diabetes Association, 2003h). See the ICSI Hypertension Diagnosis and Treatment guideline, the ICSI Lipid Screening guideline, the ICSI Preventive Services in Adults guideline and the Stable Coronary Artery Disease guideline.

Evaluate for Depression

Identification and management of depression is an important aspect of diabetes care. Intervention studies have demonstrated that when depression is treated, both quality of life and glycemic control improve. Counseling may be effective, especially among those who are having difficulty adjusting to the diagnosis of diabetes or are having difficulty living with diabetes. Pharmacotherapy for depression is also effective. The ICSI Treatment of Depression guidelines provide more detailed suggestions for the management of depression.

Treatment of Diabetes During Pregnancy

Although there is evidence that oral glyburide is safe in pregnancy, the current practice is to have women control their diabetes with insulin when they are pregnant. If you have type 2 diabetes and you are using oral agents for your diabetes, you will be switched over to insulin before you start trying to get pregnant. Not all insulins, however, are approved for use during pregnancy. The fast-acting insulin analogs insulin lispro and insulin aspart are safe. Currently, the only long-acting insulin used during pregnancy is NPH. Recently, a small study of insulin glargine used in thirty-two pregnancies did not show any problems. There is no information about using insulin detemir during pregnancy. The goal of treatment is to get your HbA1c level into the normal range before you try to get pregnant. The time it takes to do this varies, so you may want to plan at Once you have stable glucose levels in the target range, with a normal HbA1c, then you can try to get pregnant. Once you are...

Adoption of preconception care programs why did I not know about this with my last pregnancy

PCC has been shown to be highly effective in increasing the success of pregnancy in women with preexisting DM, yet only about a third of women attend PCC programs (19). One study found that women who received PCC were older, more likely to be white, married, living with their partners, and had higher education and income than those who did not receive PCC. PCC patients were also more likely to have DM1. Importantly, the patients' health providers were more likely to have encouraged PCC with patients before pregnancy (83). Similar findings were seen in a study published in 1998 (28). A multicenter study found that about one-half of women recall receiving preconception glucose counseling and one-third recall receiving preconception family planning counseling from their primary care physicians. Male physicians were significantly more likely to provide counseling than female physicians while older, heavier patients were less likely to have been counseled by their primary care physicians...

Obesity and Type Diabetes in Children

I Polycystic ovarian syndrome, also discussed in Chapter 5, leading to infertility, abnormal menstrual periods and hairiness in girls i Try to have a normal weight before you become pregnant. i Exercise throughout your pregnancy. i Breast feed for at least three months. i Eat meals together as a family. i Avoid sugary drinks and fatty foods.

Metformin Clomiphene Citrate or Both for Ovulation Induction in PCOS

Given the demonstrated efficacy of metformin as monotherapy in increasing ovulation, the question arises whether it might constitute first-line therapy in the treatment of the anovulatory infertility of PCOS. The literature on this issue is conflicting and controversial. Palombo et al. performed a prospective, randomized, double-blind trial of metformin compared with clomiphene 150 mg in 100 nonobese PCOS patients (40). While there was no difference in ovulation rates, the pregnancy rate was significantly higher in the metformin group (15.5 ) than in the clomiphene group (7.2 ) (p 0.009) (40). The cumulative pregnancy rate was 68.9 for the metformin group as compared with 34 for the clomiphene group (p < 0.001). Moll et al. performed a randomized, double-blind trial that examined the effects of metformin compared with placebo given with clomiphene in 228 women with PCOS and found no significant differences in ovulation or pregnancy rates between the two groups (64). In the largest...

Pathophysiology Of Macrosomia

Pathophysiology Undernutrition

Case finding is justified if the condition tested for is sufficiently common to justify the investment and type 2 diabetes is sufficiently common in obese children and youth to justify testing such youngsters, especially those with high-risk ethnicity or family history. Another criterion for case finding is that the condition tested for be serious in terms of morbidity and mortality, which is unquestionably true of type 2 diabetes in children because of the association with increased cardiovascular risk factors of hypertension and dyslipidemia, hyperandrogenism infertility, and early onset of microvascular disease. The condition tested for should have a prolonged latency period without symptoms, during which abnormality can be detected. Type 2 diabetes in children is often detected in the asymptomatic state, and albuminuria may already be present at the time of diagnosis, indicative of a prolonged latency (63).

Laparoscopic Ovarian Drilling

A recent Cochrane review revealed no significant difference in live birth or clinical pregnancy rate between LOD and gonadotropins while multiple gestation rates were lower with ovarian drilling (1 vs. 16 ) (98). Miscarriage rates appear to be similar between the two groups. While one LOD procedure is less expensive than gonadotropin therapy, it carries the risks of general anesthesia and postoperative adhesions, although less than with traditional ovarian wedge resection. Furthermore, it is unclear if there are long-term effects of LOD on ovarian function (98).

Vitamins and Minerals

If you are thinking about becoming pregnant or are pregnant, you have slightly different nutritional needs. You may need a prenatal vitamin or a multivitamin. Folate is generally recommended during pregnancy. Check with your dietitian or doctor about your needs (see the section on Medical Nutrition Therapy).

Optimal Timing and Frequency

Manderson et al. compared a preprandial monitoring group with a PPG monitoring group in 61 pregnant women with DM1 who were randomly assigned at 16-weeks gestation to using memory-based glucose reflectance meters throughout pregnancy (58). Maternal age, parity, age of onset of diabetes, number of prior miscarriages, smoking status, social class, weight gain in pregnancy, and compliance with therapy were similar in the two groups. However, the postprandial monitoring group had greater success in achieving glycemic control targets than the preprandial monitoring group (55 vs. 30 ) (58). The A1C assay provides information about the degree of long-term glucose control that is not otherwise obtainable in the usual clinical setting. Therefore, the A1C goal prior to pregnancy is to achieve the lowest A1C value as close to normal as possible without increasing hypoglycemia. Poorly controlled pregnant women with high A1C levels early in pregnancy have an increased risk of spontaneous abortion...

Because I had gestational diabetes I might get diabetes when Im older

Don't forget that you can become pregnant again soon after you give birth. Even if you have not had a period, you can still ovulate. And breastfeeding does not necessarily prevent you from becoming pregnant. So, before you resume having intercourse, be sure you are using effective birth control.

Realizing risks to mother and baby

The hemoglobin A1c (see Chapter 7) is an excellent measurement of overall glucose control and provides a good indicator for the risk of miscarriage. If a pregnant woman's hemoglobin A1c is high, it indicates that she was in poor glucose control at conception, and the likelihood of a miscarriage is greater. If overall glucose control is normal, the baby of the woman with diabetes is no more likely to be miscarried than that of a woman without diabetes. The major concern of a woman with pregestational diabetes is to be under good blood glucose control at the time of conception. Both miscarriages and congenital malformations are a result of poor glucose control at conception and shortly thereafter. Both high blood glucose and low blood glucose can induce malformations. (For more on managing diabetes, see Part III.)

Medical Complications

Obesity denotes ingestion of excess calories but it does not necessarily denote intake of excess micronu-trients. These children are at risk for iron deficiency and have been shown to have this alteration frequently, though they may not present anemia (96). There has been increasing evidence that maternal obesity is associated with an increased risk of congenital malformations, particularly neural tube defects (97,98). Folic acid may not play a protective role in obese women (99). These findings add to the long list of obstetric morbidities among overweight pregnant women and point to the need to prevent excess weight gain in young women who may get pregnant.

Franks Et Al Hum Reprod 1997 12 2641-8

Fedorsak P, Dale PO, Storeng R et al. (2001) The impact of obesity and insulin resistance on the outcome of IVF or ICSI in women with polycystic ovary syndrome. Hum Reprod 16 1086-91. Hull MG (1987) Epidemiology of infertility and polycystic ovarian disease endocrinological and demographic studies. Gynaecol Endocrinol 1 235-45.

Pregnancy Induced Hypertension

To further investigate the role of obesity in PIH in women with PCOS, de Vries et al. performed a retrospective case-control study examining the incidence of PIH in patients with and without PCOS who were treated for infertility (188). While the overall incidence of PIH was similar in both groups, PCOS patients had a higher incidence of preeclampsia (14 vs. 2.5 , p 0.02) regardless of BMI, ovulation induction, age and parity. A retrospective cohort study by Radon et al. found that women with PCOS had an increased risk of preeclampsia during pregnancy (OR 15.0, CI 1.9-121.5) compared to age- and weight-matched controls (163). In a prospective cohort study, Bjercke et al. found an increased incidence of gestational hypertension among PCOS women compared to controls who had undergone assisted reproduction (11.5 vs. 0.3 , p < 0.01) (189). Additionally, preeclampsia was increased among insulin-resistant PCOS patients compared to noninsulin-resistant PCOS patients and controls, supporting...

Counseling and Preconception Care Recommendations to Reduce Maternal and Fetal Risks of Preexisting Diabetes What Are

Fertility Will We Have Trouble Getting Pregnant women with a BMI greater than 30 kg m2 have a much higher risk of infertility and a higher risk of miscarriage (30). A more detailed discussion of fertility in these settings is provided in Chap. 10. Recommendation. Some women with preexisting diabetes may have trouble conceiving, but most will not. Clinicians should maintain a high index of suspicion for PCOS, and if clinical criteria are met, further investigation for PCOS and possibly, congenital adrenal hyperplasia may be warranted. If infertility is documented or there are other clinical concerns, referral to a reproductive endocrinologist may be indicated. Macrovascular Disease Should I Have a Stress Test Before Becoming Pregnant Spontaneous Abortion Am I At Risk for Miscarriage Spontaneous abortion occurs at a higher rate in pregnancies complicated by diabetes. A Danish study of women with type 1 diabetes showed a 17.5 miscarriage rate compared with 10-12 in the general...

THE pREvALENcE of Diabetes IN WoMen In Third WoRLD couNTRIEs

Epidemiologic characteristics of gestational diabetes were assessed in an ethnically diverse cohort of 10,187 women who had undergone standardized screening for glucose intolerance and who delivered a singleton infant at the Mount Sinai Medical Center in New York City between January 1987 and December 1989. The overall prevalence of gestational diabetes was 3.2 . Multiple logistic regression analysis showed excess risks for Oriental women, Hispanics born in Puerto Rico or elsewhere outside the USA, women from the Indian subcontinent and the Middle East, older mothers, heavier women, those with a positive family history of diabetes, women with a history of infertility, and those who delivered on the clinic service. These data suggest that, after controlling for traditional risk factors (maternal age, prepregnancy weight, and a family history of diabetes),

Genitourinary Autonomic Neuropathy

Phentolamine or prostaglandin E (alprostadil, 20 g) will result in an increase of blood flow into the penis, resulting in tumescence and rigidity. A constricting band must then be applied to the base of the penis, which must be immediately removed after intercourse. Sustained erections in excess of 2 h may require immediate medical therapy with epinephrine to avoid priapism. Retrograde ejaculation, a cause of infertility, has been successfully treated with an antihistamine (159). Treatment for female sexual dysfunction involves recognition, vaginal lubricants, and estrogen creams (160).

Diabetic Nephropathy And Perinatal Outcome

Perinatal outcome in women with ESRD on dialysis is expectedly poor, with few pregnancies reaching term or normal birth weight published series include patients with all forms of renal failure, including diabetes 210,213216,218, 238 . In the largest national registry series only 42 of 320 pregnancies resulted in surviving infants, but survival was better at 73.6 in women who conceived before starting dialysis 213 . The same differential regarding perinatal survival was seen in a smaller national survey in Belgium 215 . In women becoming pregnant already on dialysis, there is a continuum of mid-trimester fetal loss (21 ) (often with severe growth restriction) and preterm delivery before 28 weeks gestation in 18 213,214 . Obstetric complications include polyhydramnios and placental abruption 210,212,214216 . Pregnancy outcome does not seem to differ between women using hemodialysis vs. continuous ambulatory peritoneal dialysis, but is worse with severe hypertension in either group...

Thiazolidinediones in Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is characterized by menstrual irregularities, infertility, hyperandro-genism, obesity, and insulin resistance. In a study of rosiglitazone (4 mg twice daily for 2 months) with or without clomiphene in 25 women with PCOS who had not responded to clomiphene alone, ovulatory rates were higher in the combined versus monotherapy groups (77 and 33 , respectively) 53 .

Pregnancy

It is important to talk to your provider and dietitian before you decide to become pregnant, because good nutrition starts even before conception. For instance, your provider or dietitian will advise you to take folate as a precaution against neural tube defects, which can occur early in the baby's development. Having near-normal blood glucose levels before conceiving is another safeguard against birth defects. If you are overweight, a calorie-restricted diet may be recommended before you conceive.

Planning Pregnancy

From her work with women with diabetes in the Joslin Clinic more than 50 years ago, Priscilla White observed that 'To many, if not all, of these women, life lacks meaning, and even may be unendurable without successful child-bearing'7. Fortunately, nowadays there are in principle no medical reasons for a woman with established diabetes not to become pregnant provided she takes adequate care of her blood glucose control before conception and throughout the pregnancy. Only on rare occasions may doctors advise against pregnancy, for instance when the woman with diabetes has seriously advanced microvascular complications, and the pregnancy may accelerate these complications and cause severe physical disability or even death in the diabetic woman8. struggling with infertility to take a more laisser faire attitude towards pregnancy, this approach may be less useful in women with diabetes, as developing a more accepting attitude may be incompatible with staying adherent to the diabetes...

Exercise

Intensive insulin therapy during preconception and during pregnancy of women with DM1 can significantly reduce the risk of adverse pregnancy outcomes to a level similar to the risk among women with normal pregnancies (14). Good glycemic control in DM2 should also be achieved prior to pregnancy however, women who are being treated with oral hypoglycemic agents must discontinue the oral agents when they become pregnant. In addition, it may be possible for some women with diet-controlled DM2 to achieve good glycemic control with diet and exercise alone during pregnancy. When these interventions fail, then insulin treatment is required for pregnant women with DM2.

Using test results

I It permits me to encourage a woman with T1DM who wants to get pregnant to go ahead if the value is satisfactory or to tell her to wait if the level isn't right. If a pregnant woman's hemoglobin A1c is high (over 8 percent for example), it mean's that her blood glucose was high on average at the time of conception of the baby. As a result, she's at high risk of delivering a baby with a congenital malformation. If she isn't yet pregnant, a measurement of the hemoglobin A1c tells her whether she can become pregnant now or should wait until her glucose is under better control. (See Chapter 16 for details on T1DM during pregnancy.)

Genetic Factors

Although preeclampsia is sporadic, genetic factors are thought to play a role in disease susceptibility. Primigravid women with a family history of preeclampsia have a two- to fivefold higher risk of preeclampsia than primigravid women without a family history (71-74). Women who become pregnant by a man whose previous partner had preeclampsia are at higher risk than those who become pregnant by a man whose prior partner was normotensive (75). The spouses of men who were the product of a pregnancy complicated by preeclampsia are also more likely to develop preeclampsia than the spouses of men without a history (73, 76). These data suggest that both maternal and paternal contributions to fetal genes may have a role in subsequent preeclampsia. Though several candidate genes have been linked to preeclampsia (angiotensinogen gene variant T235 and endothelial nitric oxide synthase), larger studies have not found them to be important for disease susceptibility (77). Genome scanning of...

For Women

Women with diabetes have the same birth control options as other women. The pill, intrauterine device (IUD), barrier methods, and spermicides are all ways to reduce the risk of unplanned pregnancy. The rhythm method, in which women predict ovulation and avoid intercourse during fertile times, is generally not a sufficiently reliable method of birth control for women with diabetes. A tubal ligation may be an option if you are sure you never want to become pregnant, because it is nearly impossible to reverse.

Tamara C Takoudes MD

Specific concerns in the first trimester include an increased risk of miscarriage and careful evaluation of the maternal risks specific to the patient's cardiovascular, renal, thyroid, and ophthalmologic status. In the early second trimester, fetal testing for congenital birth defects and other diagnostic procedures are recommended. This trimester is complicated by increasing insulin requirements that usually continue into the third trimester. In late pregnancy, concern shifts to fetal size, preeclampsia, stillbirth, and deciding delivery timing and route. Key words Hemoglobin A1c Congenital anomalies Miscarriage Preeclampsia Stillbirth Insulin Macrosomia.

Foodborne illness

Pregnant women and their unborn babies are susceptible to food-borne illnesses. Specific concerns include Listeria monocytogenes, Salmonella, and Toxoplasma gondii. Infections from these food-borne illnesses can be passed to the fetus and have the potential for causing a miscarriage, stillbirth, or serious health problems for the newborn. Pregnant women are advised to avoid hot dogs, cold cuts, soft cheeses such as Feta, Brie, Camembert, blue-veined cheeses, or Mexican style cheeses, and all unpasteurized milk, milk products, and cheese. Other foods to avoid are pates, meat spreads, and refrigerated smoked seafood. Women are advised to avoid cleaning cat litter boxes and to avoid touching pets during food preparation (20).

Birth Control

A baby's organs are formed in the first six weeks after conception. Most women are not even sure that they are pregnant during this critical time. High blood glucose levels can interfere with this development, and the baby has a greater chance of a birth defect. Also, when blood glucose levels are high, the risk of spontaneous miscarriage may double in early pregnancy. You increase your chances for a healthy child when you plan

Lifestyle Changes

Lifestyle modification is thus a key component for the improvement of reproductive function for overweight, anovulatory women with PCOS (138,149-151). Weight loss should be encouraged prior to ovulation induction treatments, since these are less effective when BMI is > 28-30 kg m2 (152). Monitoring treatment is also harder in the obese as visualization of the ovaries is more difficult which raises the risk of multiple ovulations and pregnancies. Furthermore, pregnancy carries greater risks in the obese, such as miscarriage, gestational diabetes and hypertension (153-156). The main component of diet should be calorie restriction (157,158), with an additional effect from diet composition (49).

Epidemiology

The development and progression of retinopathy most certainly is influenced by many factors, including race, gender, hypertension and other vasculopathic systemic disorders. Epidemiologic studies have been unable to conclusively demonstrate a definitive association between these factors and retinopathy in patients with type 2 diabetes (9-15). Pregnancy, however, has been shown to be a significant risk factor for development and progression of diabetic retinopathy. In women without retinopathy at the start of pregnancy, 10 will show mild retinal changes that resolve after delivery. However, in women with pre-existing retinopathy, up to 25 will progress to proliferative changes during pregnancy (16). Those at greatest risk for severe visual deterioration are those who are rapidly brought under strict control (17). Women should be encouraged to have their eyes examined and their glycemic control optimized prior to becoming pregnant.

Contraception

Intra-uterine contraceptive devices (IUCDs) are rarely used in nulliparous women. In any woman there is a risk of pelvic infection rarely leading to infertility. This risk is greater in women with diabetes because of their propensity to infection generally. Older forms of IUCD underwent unusual chemical change in some women with diabetes and failed to prevent conception. This does not appear to be a problem with currently used IUCDs.

Obesity

The importance of obesity in PCOS is also supported by the finding that obesity can profoundly affect quality-of-life (QoL) independent of the presence of other clinical symptoms in otherwise healthy subjects (56). Interestingly, obesity is linked strongly to the physical dimension of QoL, rather than with psychosocial status (57) and social adjustment (58). A variety of studies demonstrated that BMI and hirsutism are the primary mediators in the relationship between PCOS and the reductions in QoL (59-62). In addition, in obese patients the impact of weight reduction on QoL has been well established (58). On the basis of the data documenting the psychological and emotional consequences of changes in outer appearance, clinical interventions in PCOS women that influence obesity, hirsutism, acne, menstrual disturbances or infertility would be expected to improve overall QoL (63).

Weight Problems

Try removing all gold gold teeth, gold jewelry and gold rings. Replace them with non metal varieties. After removing the gold, pull the remaining gold out of your tissues with thioctic acid (2 or 3 a day for several months). Make sure kidneys are able to excrete the gold instead of making crystals by doing a kidney cleanse. Gold accumulates in the pancreas, the brain (possibly in a control center here) and the ovaries (causes some infertility here). Also try clearing the body of all bacteria and parasites by regularly using a zapper. Use the Bowel Program (page 546) to evict the last of the Shigellas. Be very careful to avoid nonsterile dairy products. Try cleansing your liver by doing liver cleanses. Get 3,000 stones out.

Anorexia

Anorexia can cause infertility, osteoporosis, and irritable bowel syndrome however, for those with anorexia and DM1 the risks are even greater. Women with diabetes and anorexia have a mortality rate of 34.6 per 1000 person-years, whereas those with anorexia without diabetes have only a 2.2 per 1000 person-years (73). This staggering difference highlights the essential need for physicians to screen for this disorder, regardless of its prevalence. In addition, people with diabetes face a slew of other potential complications. Skipping meals can put people with diabetes at risk for hypoglycemia, which can result in a variety of symptoms including mental confusion, impaired judgment, mood changes, seizures, coma, and possibly death (4).

Metformin

Because of the increasing evidence of the role of insulin resistance in the pathogenesis of PCOS, medications that improve insulin sensitivity and lower circulating insulin have been investigated for treatment of anovulatory infertility. Metformin, an oral biguanide used to treat type 2 diabetes mellitus, has proven effective in decreasing ovarian androgen secretion in women with PCOS (52-57). Metformin may also decrease adrenal steroidogenesis, which may also be elevated due to hyperinsulinemia (58). Studies have shown that it is effective in improving ovulation rates in patients naive to fertility treatments as well as those with clomiphene resistance (59-61). Several studies have found that metformin's effects to improve ovulation may require several months (up to 3-6) of treatment in many patients, likely because metformin is a metabolic drug that acts indirectly to improve insulin sensitivity, which subsequently improves reproductive function (40, 62). The starting dose is...

Definition

B) one or more prescriptions for insulin in the last 12 months (coding is available on disk from either ICSI or from the NCQA.org website) regular insulin, NPH, Lente, Lispro, Humulin, 70 30, 75 25, 50 50, Novolin, Ultralente, Glargine, Aspart, Multiple Daily Injections or Continuous Subcutaneous Infusion of Insulin, Insulin Pump, Insulin Pen, Semilente, Novolin, Penfill, Ultralente, Velosulin, Humalog, OR c) one or more prescriptions for oral agents in the last 12 months (coding is available on disk from either ICSI or from the NCQA.org website) Acarbose, Miglitol Glycet, Amaryl, Diabeta, Diabinese, Glimepiride, Glipizide, Glipizide XL, Glucophage, Glucotrol, Glucotrol XL, Glybu-ride, Glynase, Metformin, Micronase, Prandin, Starlix, Glucovance, Repaglinide, Precose, Tolazamide, Tolamide, Tolbutamide, Tolinase, Rosiglitazone, Pioglitazone.

Sodium

Medical nutrition therapy for hypertension control focuses on weight reduction and recommended sodium intakes of 1,500-2,400 mg per day. Additional recommendations include consuming five to nine servings of fruits and vegetables daily, and two to four daily servings of low-fat dairy products rich in calcium, magnesium, and potassium. Please refer to the ICSI Hypertension guideline for additional information. Pastors, 2002). See the ICSI Prevention and Management of Obesity guideline.

Fertility

Recent studies suggest that fertility in women with type 1 diabetes is the same as in women without diabetes. Polycystic ovary syndrome (PCOS) is a risk factor for type 2 diabetes, and women with this condition may have difficulty with ovulation and getting pregnant. Metformin, pioglitazone, and rosiglitazone can make the menstrual cycles regular and cause ovulation in women with polycystic ovary syndrome. Metformin is frequently used for this purpose, and the medication is stopped when the woman becomes pregnant.

High Blood Pressure

Change your galvanized pipes to PVC plastic. If you believe you already have plastic pipes or all copper (which leads to leukemia, schizophrenia and fertility problems) you will need to search every inch of plumbing for a very short piece of galvanized pipe left in the system A piece as short as a 2 inch T or Y can be causing all the trouble.

Puberty

Menstruation can cause cyclical hyperglycaemia (sometimes hypoglycaemia). Do not increase the insulin so much that the young person needs to eat more and becomes overweight. However, food intake usually increases around puberty. Diabetic girls who have started to menstruate must be told about sexual intercourse, the possibility of pregnancy, and the need for family planning in diabetes. With the recent AIDS prevention campaigns, and ready availability of condoms in shops, sexual ignorance is less common than before. An unsuspected pregnancy can precipitate diabetic ketoacidosis and it is particularly important to avoid unwanted pregnancy in diabetic girls.

Age Of Menopause

DM1 can also occur as part of the autoimmune polyglandular type 2 syndrome. The polyglandular type 2 syndrome is the most common of the immunoendocrinopathy syndromes and is inherited in an autosomal dominant pattern with variable penetrance (19). Premature gonadal failure can be a manifestation of this syndrome. Women with DM1 and another autoimmune conditions or with a family history of the polyglandular failure syndrome should be informed and counseled about associated conditions. The association with premature gonadal failure may be important to women with DM1 for purposes of family planning.

Aromatase Inhibitors

Aromatase inhibitors, such as letrozole and anastrozole, have been used for ovulation induction in anovulatory infertility or as adjunctive treatment to gonadotropins for induction of multiple follicles for assisted reproduction (90). Their mechanism of action is through preventing conversion of androgen to estrogen. Aromatase inhibitors have a relatively short half-life (approximately 45 h) and therefore cause less adverse effects on estrogen target tissues and no downregulation of estrogen receptors as is seen with clomiphene citrate (90, 91). Begum et al. compared the efficacy of letrozole 7.5 mg to clomiphene 150 mg in patients with PCOS who did not respond to 100 mg of clomiphene (91). Patients treated with letrozole had significantly higher ovulation and pregnancy rates. Bayar et al. compared the use of letrozole 2.5 mg with clomiphene 100 mg in a prospective randomized study of 74 infertile PCOS women and found the two treatments to be comparable in ovulation and pregnancy...

Acanthosis Nigricans

Polycystic ovary syndrome is typically diagnosed in patients with symptoms of androgen excess, i.e. infertility, hirsuitism or oligomenorrhea, and elevated serum androgen levels, and is associated with insulin resistance. The prevalence of polycystic ovary syndrome is 20 of asymptomatic women in England as detected by ultrasound (97,98) Among 18-40-year-old Asian Indian women in England the prevalence on ultrasound was > 50 , and polycystic ovary syndrome was significantly associated with acanthosis nigricans and elevated fasting blood glucose, in addition to the recognized symptoms of hirsuitism, infertility and menstrual irregularities (99). Using a short intravenous glucose tolerance test, the presence of polycystic ovary syndrome in these women accounted for a reduction in insulin sensitivity comparable to that seen in women who had

Gestational Diabetes

In normal women, pregnancy is known to increase insulin resistance, which is compensated by hyperinsulinemia effects are maximal in the third trimester (115, 156). Women with PCOS have greater insulin resistance than normal women and their pancreatic beta cells may be unable to fully compensate for the additional insulin resistance of pregnancy, making them more prone to the development of GDM (157). They are also more likely to be obese and due to the increased rate of infertility in women with PCOS, they frequently conceive at an older age. Both obesity and advanced age increase the risk for GDM (152). Studies have sought to determine if the increased risk for GDM in women with PCOS is due to insulin resistance or other factors that are associated with the syndrome.

The paradigm of pcos

PCOS is one of the most common causes of ovulatory infertility, affecting 4-7 of women. After the original description by Stein and Leventhal (76), this syndrome has been defined in different ways over the last 15 years. In 1990 the National Institutes of Health (NIH) established very simple new diagnostic criteria, which were based on the presence of hyperandrogenism (either clinical, such as hirsutism, etc., or biochemical) and chronic oligo-anovulation, with the exclusion of other causes of blood androgen excess, such as adult-onset congenital adrenal hyperplasia, Cushing's syndrome, androgen-secreting neoplasms, and others (77). More recently, a consensus conference held in Rotterdam, in 2003 (78), re-examined the 1990 criteria and admitted the appropriateness of including ultrasound morphology of the ovaries among the diagnostic criteria of the syndrome. It was also established that at least two of the proposed diagnostic criteria, i.e., oligo-anovulation, clinical and or...

Gonadotropin Therapy

A second-line option for infertility treatment is direct gonadotropin therapy with either FSH or human menopausal gonadotropin (hMG). Because of the increased number of FSH-responsive follicles in polycystic ovaries, patients with PCOS are more at risk for OHSS and multiple gestations (82-84). A low-dose, step-up protocol has been developed, which yields an increased pregnancy rate while reducing the incidence of OHSS and multiple gestations (83, 85, 86). Treatment consists of employing a low starting dose, typically 50 or 75 international units (IU) per day, and using small incremental dose increases when necessary to initiate and continue follicular development, up to maximum of 225 IU (6, 85). Ultrasounds are performed every 3-4 days to monitor follicle development, and ovulation is triggered by intramuscular human chorionic gonadotropin (hCG) injection (85). Treatment is typically discontinued if more than three follicles develop to reduce the risk of OHSS and multiple gestations...

Early Pregnancy Loss

Early pregnancy loss (EPL) is defined as miscarriage of a clinically recognized pregnancy during the first trimester (39). While EPL occurs in 10-15 of normal women (116), rates in women with PCOS are as high as 30-50 (117). Because of the prevalence of infertility in patients with PCOS, many women require fertility treatments which in themselves increase the prevalence of miscarriage (118). However, several studies in women undergoing fertility treatment with IVF have demonstrated that women with PCOS have a higher miscarriage rate than controls (107, 108, 119, 120). Although there has been considerable research interest in this area, the exact mechanisms underlying the increased risk of EPL in women with PCOS are not clearly elucidated. Initially, EPL in PCOS was thought to be due to elevated LH levels (8, 107, 117, 121, 122). A prospective study of women by Regan et al. revealed that regularly menstruating women with higher LH values were less likely to conceive (67 vs. 88 ) and...

Thiazolidenediones

Thiazolidenediones (TZDs) have also been examined for their possible role in the treatment of infertility in PCOS. The main mechanism of action is through activation of the nuclear peroxisome proliferator-activated receptor gamma (PPAR-g), which decreases peripheral insulin resistance (73, 74). Troglitazone was the first drug of this class that was shown to improve ovulation rates, hyperandrogenemia and insulin resistance compared with placebo (75). It has been shown in vitro to impede LH and insulin stimulation of ovarian androgen production as thecal cells also possess PPAR-g receptors (76). Troglitazone has since been withdrawn from the market due to concerns of hepatotoxicity. In a randomized, double-blind, controlled trial, Brettenthaler et al. showed significantly improved insulin sensitivity, hyperandrogenism and ovulation rates during treatment with pioglitazone (80). When pioglitazone was added in a small sample of patients nonresponsive to metformin, patients were found to...

Clomiphene Citrate

Clomiphene citrate, an indirect stimulator of FSH secretion, has been the traditional approach to ovulation induction in infertile patients with PCOS. It is typically given at a dose of 50 mg per day for 5 days starting from day 2 to day 5 of spontaneous or induced menses. The dose of clomiphene can be increased in increments of 50 mg per day each cycle if ovulation is not achieved up to a maximum dose of 250 mg, although doses in excess of 150 mg are not typically prescribed (6). Ovulation occurs in 60-85 of patients given clomiphene, 30-40 of whom become pregnant (9, 30, 31). Approximately 75 of those who conceive on clomiphene become pregnant during the first three cycles of treatment (32-34). There is an increased risk of ovarian and uterine cancer in patients continuing prolonged ovulation induction with clomiphene (35-37). Therefore, treatment is usually attempted for 3-6 cycles but no more than 12 cycles (9). While clomiphene increases the number of follicles attaining...

Weight Loss

Excess body fat accentuates insulin resistance in patients with PCOS, and obese women with PCOS are more likely than lean women to manifest menstrual irregularities (12). Furthermore, increased body mass index (BMI) is associated with impaired response to standard doses of clomi-phene citrate (18,19). Obesity, independent from hyperinsulinemia, is related to lower oocyte retrieval in IVF and increased total FSH requirements for ovarian stimulation (20, 21). Improved diet and exercise alone, without significant weight loss, may improve ovulation rates. Huber-Buchholz et al. studied the relationship between insulin sensitivity and ovulation in 18 anovulatory obese PCOS women with infertility before and after a 6-month intervention of gradual dietary changes and a moderate exercise regimen (23, 24). Anovulatory subjects who regained ovulation during the study showed an 11 reduction in central fat, a 39 reduction in LH levels and improved insulin sensitivity. This was achieved with...

Pregnancy Guide

Pregnancy Guide

A Beginner's Guide to Healthy Pregnancy. If you suspect, or know, that you are pregnant, we ho pe you have already visited your doctor. Presuming that you have confirmed your suspicions and that this is your first child, or that you wish to take better care of yourself d uring pregnancy than you did during your other pregnancies; you have come to the right place.

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