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Sunday, May 27, 2012

Prevalence of Polycystic Ovarian Syndrome in Nepal

                                                                                                           Dr. Uma Shrivastava 
                                                                                          Infertility Centre, Bijulibazar, Kathmandu


Most common cause of female infertility
(Nestler JE Fertil. Steril:77: 209 March 2002)                                                              
Presents with Anovulation & Infertility
Multiple small cortical follicles with typical necklace like appearance in both ovaries
Vague multi-systemic endocrine disorder
High level of hormones LH: FSH ratio, DHEAS, Prolactin, TSH, Insulin etc.
By the age of 40 years up to 40% of women may develop type 2 diabetes or impaired glucose tolerance
Women with PCOS are at the risk of MI & heart disease seven times more than normal women

Prevalence rate 

Among women of reproductive age 28-31%
(Knochenhauer ES. J Clin Endocrinol Metab. 1998 Sep;83(9):3078-82 & 2000 Jul;85(7):2434- 8)
Among obese women 28-30%
Alvarez-Blasco F. Arch Intern Med. 2006 Oct. 23;166(19):2081-6)
Among Hirsute 23%
(J Clin Endocrinol Metab. 2000 Vol. 85, No. 11 4182-4187)
Among Frank diabetics 33%
(Fertil Steril. 2006 Aug;86(2):405-10. Jun8)
Genetic link –affected sisters up to 80%
(Fertil Steril. 2001 Jan;75(1):53-8)
Among ischaemic heart disease 46%
(MJA 1998; 169: 537-540)

Signs & Symptoms 

1. Early Cycle
2. Regular Cycle
3. Late Cycle
Acanthosis nigricans


Clearly unknown – an Enigma
Insulin resistance
Hyper-secretion of Lutenizing hormone
Genetic predisposition  


 I. Insulin Resistance
Normally glucose is passed into the cell through insulin receptors doorway
The average healthy body contains 20,000 insulin receptor sites per cell
The average overweight individual with PCOS can have as few as 5,000 insulin receptor sites
In PCOS few receptor sites will not allow all the glucose into the cell
Glucose remains in the blood stream
Glucose is converted into fat and stored via the blood stream throughout the body
Excess fat lead to weight gain and obesity

II. Increased peripheral Estradiol & estrone levels
Stimulates numerous follicular growth
Some follicles undergo luteinization
Stimulates stroma & theca of ovary, increase surface
Multiple follicles surrounded by hyperplastic theca
Some follicles remain stunted & few undergo atresia
Prevent normal follicular development - Anovulation !
III. Androgen excess
Stimulates stroma & theca of ovary, increase surface
Multiple follicles surrounded by hyperplastic theca
P450 aromatase gene mutation
Production of excess Androgen & testosterone

IV.  Abnormal gonadotropin dynamics
Altered diurnal rhythm of LH secretion
Increased LH pulse frequency
Stimulates numerous follicular growth
Feedback increase in FSH
More new follicles growth
Accelerates LH production & suppress FSH
Elevated LH:FSH ratio

Materials & Methods

Retrospective study conducted at the Infertility & IVF Centre, Kathmandu
A counseling & laboratory based study
Duration (Sept. 2003 - Nov. 2006)
The study population- women willing to conceive & adolescence with irregular menstrual cycle
Total female analyzed = 3740

 PCOS diagnostic criteria

A. Symptomatic (Counseling)
Irregular cycle
Positive family history
B. Laboratory Evaluation
High level of hormones (LH, Insulin, Androgen, Prolactin, Estrogen etc.)
Ultrasonic evaluation – Abdominal & trans-vaginal ultrasonography of the ovaries
•       Black pearl necklace-like appearance of multiple cortical cysts
Ovarian volume of more than 10 cm3
C. Exclusion of secondary causes

Management of PCOS

Ovulation induction - Clomiphene citrate , FSH, GnRH etc.
Insulin sensitizing agents – Glucophase, Pioglitazone, D-chiro inositol etc.
Weight reduction - Diet management
OC pills
Ovarian volume reduction-Surgical procedure


Previous studies          

Up to 31% prevalence PCOS
(Asuncion M. J Clin Endocrinol Metab. 2000 Jul;85(7):2434-8)
Higher prevalence in Indian than Chinese ethnic
       (Williamson K. Aust N Z J Obstet Gynaecol.2001 May;41(2):202-6)

Our study (Infertility Centre)

Total female analyzed = 3740
Hormonal & other disorder = 2200 (58.9%)
Structural & functional PCOS = 1500 (40%)
Cut off = 40
About 400 PCOS (40%) in 1000 reproductive disorders
More studies needed in this area
                                                                      (Paper presented at NESOG Conference 2007)