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
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
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
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)
May also be treatable with injectable medications and intrauterine
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
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
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