Microsoft word - m.i. infertility - polycistic ovarian syndrome _version 3.0 - december 2011_.docx

Medical Information to Support the Decisions of TUECs INFERTILITY/POLYCYSTIC OVARIAN SYNDROME INFERTILITY/POLYCYSTIC OVARIAN SYNDROME

Introduction
Infertility is defined as the absence of pregnancy following 12 months of unprotected intercourse. Infertility may be caused by Ovulatory Dysfunction, Blocked Fallopian Tubes, Male Factor Infertility or Unexplained Causes. Ovulatory Dysfunction can be caused by hypothalamic causes, endocrinopathies (hyperprolactinemia, thyroid dysfunction) or ovarian causes (Polycystic Ovarian Syndrome, ovarian failure). Only those causes of infertility which require a TUE will be addressed in this document. Ovulatory Dysfunction: Polycystic ovarian syndrome (PCOS)
1. Diagnosis
Clinical evidence of androgen excess (hirsutism, acne). Ultrasound evidence of ovarian volume 10cm3, >12 follicles Altered hormonal profile is not necessary for diagnosis as serum as androgen levels (testosterone, androstenedione, DHEAS) may be in the normal or high range. Some women with PCOS will have associated insulin resistance which may manifest as impaired glucose tolerance or overt diabetes. 2. Medical best
practice
treatment
Medical Information to Support the Decisions of TUECs INFERTILITY/POLYCYSTIC OVARIAN SYNDROME Clomiphene citrate
Spironolactone
First line therapy is clomiphene Spironolactone may be used in
citrate, a weak anti estrogen.
3. Other non-
Clomiphene citrate
Spironolactone
1 N Engl J Med. 2007;365:551-566, 622-624 WADA- World Anti-Doping Program Medical Information to Support the Decisions of TUECs INFERTILITY/POLYCYSTIC OVARIAN SYNDROME prohibited
alternative
treatments?
effects that are used as first line therapy for the treatment of oral contraceptive or the Nuva-ring will increase sex hormone binding globulin as a result of the increased estrogen. This will decrease free unbound, circulating androgens resulting in decreased hirsutism. For more severe or long standing cases, larger doses of cyproterone acetate (25- 50mg) may be necessary. flutamide (non-steroidal anti-androgen) is used to treat hirsutism. Hormonal therapy can be combined with physical hair or electrolysis. A TUE may be granted for spironolactone should the athlete have proved: hirsutism in the clinical picture of PCOS] and one or more of the following criteria: 4. Consequence
Clomiphene citrate
Spironolactone
to health if
treatment is
Significantly decreased quality of Significant decreased quality of life withheld
for women with hirsutism resulting from PCOS. Medical Information to Support the Decisions of TUECs INFERTILITY/POLYCYSTIC OVARIAN SYNDROME 5. Treatment
monitoring
6. TUE validity
recommended
appropriate
cautionary
Medical Information to Support the Decisions of TUECs INFERTILITY/POLYCYSTIC OVARIAN SYNDROME Bilateral Blockage of Fallopian Tubes
1. Diagnosis
Evidence of proximal or distal blockage of tubes by hysterosalpingogram, sonohysterogram or surgery. 2. Medical best
practice
This requires controlled ovarian hyperstimulation with FSH, or FSH/LH treatment
combination. Prior to stimulation the patient may receive oral contraceptives or GnRH agonists, or may receive GnRH antagonists during stimulation. Pain management during the procedure may include: morphine, meperidine (pethidine), ketorolac, fentanyl or midazolam, as well as local lidocaine or bupivacaine. GnRH agonists (nafarelin or buserelin), and GnRH antagonists (ganirelix or cetrorelix). Narcotics may be required during the procedure – which are prohibited during competition only. Medical Information to Support the Decisions of TUECs INFERTILITY/POLYCYSTIC OVARIAN SYNDROME 3. Other non-
prohibited
alternative
hCG, Progesterone may be required in addition. treatments?
4. Consequences
to health if
Significantly decreased quality of life if infertility is unresolved. treatment is
withheld
5. Treatment
Blood hormonal profiles and ultrasound to assess ovarian response monitoring
6. TUE validity
A TUE is required for the use of the GnRH agonists and antagonists. The procedure is usually repeated at three month interval for an recommended
review process
The recommended duration of a TUE for Infertility/Polycystic Ovarian Syndrome is 2 years. If narcotics are used during the procedures, a TUE would be required but narcotics are only prohibited during the in- A TUE will be required for the procedure if narcotics are used should the procedure occur during the in-competition period only. 7. Any appropriate
cautionary
IVF is not recommended during the competitive period. Medical Information to Support the Decisions of TUECs INFERTILITY/POLYCYSTIC OVARIAN SYNDROME Male Factor Infertility necessitating advanced reproductive
technologies
1. Diagnosis
Abnormal semen analysis showing hypomobility, a high incidence of abnormal forms or decreased overall sperm count. 2. Medical best
IVF see Bilateral blockage of fallopian tubes (above) practice
May also be treatable with injectable medications and intrauterine treatment
insemination for which a TUE is not required. Medical Information to Support the Decisions of TUECs INFERTILITY/POLYCYSTIC OVARIAN SYNDROME Unexplained Infertility
1. Diagnosis
No pregnancy despite regular ovulatory cycles, open tubes, regular timed intercourse and normal semen analysis. 2. Medical best
May be treated with clomiphene citrate (see PCOS), FSH/LH (TUE not practice
required) or IVF (see Bilateral blockage of fallopian tubes). treatment
Medical Information to Support the Decisions of TUECs INFERTILITY/POLYCYSTIC OVARIAN SYNDROME Other References

CFAS (Canadian Fertility & Andrology Society) Consensus Document for the Investigation of
Infertility By First Line Physicians 2003
http://cfas.cfwebtools.com/index.cfm?objectid=62E48386-9027-F64A-799957D994FC5F65
Consensus on infertility treatment related to polycystic ovary syndrome. Fertil Steril 2008; 89(3): 505-522 Handelsman DJ, The Rationale For Banning Human Chorionic Gonadotrophin and Estrogen Blockers in Sport JCEM 19:16461653, 2006 Nattv A,Loucks,AB,Manore,MM,Sanborn,CF,Sudgot-Borgen J, Warren, MP, Acmerican College of Sports Medicine;The Female Athlete Triad MSSE10:1249 1867-1881, 2007

Source: http://www.tuewizard.org.nz/images/page_dfsnzAppForms/files/WADA_Medical_info_Infertility_POS_3.0_EN_.pdf