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Biomedical subjects

Roy Homburg

Publications and source records attributed to Roy Homburg.

7 recordsLinked to original sources
PubMed2003

The management of infertility associated with polycystic ovary syndrome.

Polycystic ovary syndrome [PCOS] is the commonest cause of anovulatory infertility. Treatment modes available are numerous mainly relying on ovarian stimulation with FSH, a reduction in insulin concentrations and a decrease in LH levels as the basis of the therapeutic principles. Clomiphene citrate is still the first line treatment and if unsuccessful is usually followed by direct FSH stimulation. This should be given in a low dose protocol, essential to avoid the otherwise prevalent complications of ovarian hyperstimulation syndrome and multiple pregnancies. The addition of a GnRH agonists, while very useful during IVF/ET, adds little to ovulation induction success whereas the position of GnRH antagonists is not yet clear. Hyperinsulinemia is the commonest contributor to the state of anovulation and its reduction, by weight loss or insulin sensitizing agents such as metformin, will alone often restore ovulation or will improve results when used in combination with other agents. Laparoscopic ovarian drilling is proving equally as successful as FSH for the induction of ovulation, particularly in thin patients with high LH concentrations. Aromatase inhibitors are presently being examined and may replace clomiphene in the future. When all else has failed, IVF/ET produces excellent results. In conclusion, there are very few women suffering from anovulatory infertility associated with PCOS who cannot be successfully treated today.

Female↗
PubMed2003

The case for initial treatment with intrauterine insemination as opposed to in vitro fertilization for idiopathic infertility.

The recent questioning of the validity of evidence used by the Royal College of Obstetricians and Gynaecologists in recommending ovarian stimulation with intrauterine insemination (IUI) as an effective treatment for couples with unexplained infertility, has re-ignited the debate on what the initial treatment for idiopathic infertility should be. The current best available evidence is used here with the conclusion that the initial treatment for idiopathic infertility should be IUI as opposed to IVF. This conclusion is reached using the results of randomized controlled trials wherever possible, live birth rates rather than pregnancy rates and taking into account efficacy; complications, especially multiple pregnancy rates; patient compliance and cost efficiency. None of these factors indicate that a change of policy to use IVF as first-line treatment in lieu of IUI for unexplained infertility is justified.

Cost-Benefit Analysis↗
PubMed2003

Ovulation induction.

Anovulation, a common cause of female infertility, is a highly curable condition. Presented here is a simple treatment-orientated diagnostic scheme. Anovulatory women with low endogenous oestradiol and follicle stimulating hormone (FSH) are treated with either pulsatile gonadotrophin releasing hormone (GnRH) or gonadotropins, and women with eu-oestrogenic anovulation (mostly with polycystic ovarian syndrome; PCOS) have first-line treatment with clomiphene citrate (CC), possibly with metformin. If CC fails, FSH is administered using a chronic low-dose protocol with small incremental dose rises. A comparison of urinary with recombinant and pure FSH with luteinising hormone (LH) containing gonadotropins is made. Recombinant products are purer and more convenient for use but are expensive. LH content has little impact except in hypogonadotropic hypogonadism or severe pituitary suppression with GnRH analogues. Aromatase inhibitors, recombinant LH and long-acting FSH may find a future place in the armamentarium.

Anovulation↗
PubMed2002

What is polycystic ovarian syndrome? A proposal for a consensus on the definition and diagnosis of polycystic ovarian syndrome.

The criteria for diagnosis and definition of polycystic ovarian syndrome used by clinicians and investigators are almost as heterogeneous as the syndrome itself. This has confused and seriously hindered the clarification of the genetics, aetiology, clinical associations and assessment of treatment and later sequelae of the syndrome. This article proposes a consensus for a unifying balanced and practical working definition for use as a standard. The proposal incorporates confirmation of the diagnosis suggested by clinical symptoms by ultrasound, and the use of hormonal estimations if typical ultrasound features are not seen and for the purpose of defining subsets of the syndrome. This consensus proposal attempts to bridge the gap between predominately American biochemical marker-based diagnosis and predominately European reliance on ultrasound as a sine qua non for diagnosis. It has been deliberately designed to be simple, practical and cheap, and if universally adopted as a standard could contribute much to all future work involving this most prevalent of syndromes.

Acne Vulgaris↗
PubMed2002

Should patients with polycystic ovarian syndrome be treated with metformin? A note of cautious optimism.

Hyperinsulinaemia has proved to be a key link in the enigmatic generation of the symptoms of polycystic ovarian syndrome (PCOS), i.e. anovulatory infertility and the skin stigmata induced by hyperandrogenism. Regression of these symptoms may be achieved by reducing the hyperinsulinaemia. As obesity exaggerates the expression of the symptoms induced by hyperinsulinaemia, a low calorie diet and lifestyle change resulting in loss of weight for obese women with PCOS is capable of reversing these symptoms. Insulin-sensitizing agents, predominantly metformin, have been examined for their ability, in all patients with PCOS, to achieve similar beneficial changes to those induced by loss of weight in the obese. While the scientific value of many of these studies is questionable and solid evidence of efficiency and safety is not complete, the honourable intent of lowering high insulin levels in this way prompts the bottom line of this debate to strike a note of cautious optimism that insulin-sensitizing agents will be of some clinical usefulness both in the short-term aiding of infertility treatment and, possibly, in the prevention of the long-term sequelae for this troublesome and very prevalent condition.

Anovulation↗
PubMedDate not supplied

Ovulation induction in perspective.

It has been suggested recently that, in some quarters, IVF be offered as first-line therapy to all infertile couples, regardless of the type of infertility. Hence, the time was thought right to scrutinise the results and complications of ovulation induction for anovulatory infertile couples. In addition to examining the outcome of conventional treatment with gonadotrophins and clomiphene citrate, special attention has been paid to the suggested improvement of results by taking into account the influence of obesity and the use of a low-dose gonadotrophin protocol. The possible contribution of more recent additions to the armamentarium such as insulin sensitizers and aromatase inhibitors, although still at an infant stage, are promising. Attention has been given to the prevention and treatment of ovarian hyperstimulation syndrome. The use of intra-uterine insemination (IUI) as an adjuvant to induction of ovulation and controlled ovarian hyperstimulation (COH) is examined. The very firm conclusion has been reached that, taking into account efficiency, complication rate and cost of treatment, at this stage, women with hypogonadotrophic hypogonadism or polycystic ovary syndrome should be offered accepted methods of ovulation induction and that couples with 'unexplained' or 'multifactorial subfertility' should still be exposed to COH with IUI and only after the failure of these therapies, be offered IVF.

Aromatase Inhibitors↗