A Comprehensive Case Report on Managing PCOS-Related Infertility: Successful Pregnancy Achieved via Controlled Ovarian Stimulation and Intracytoplasmic Sperm Injection (ICSI)

ABSTRACT

Infertility is considered a global concern, significantly contributing to females with PCOS. This case study describes the journey of a 33-year-old woman with PCOS and her 35-year-old male partner, who had been trying to conceive for over four years. They also had a history of failed intrauterine insemination (IUI) and intracytoplasmic sperm injection (ICSI) cycles despite normal semen parameters of the male partner, the female investigations revealed abnormalities in hormonal luteinizing hormone (LH) and follicle-stimulating hormone (FSH) that were the identified contributing factors. Further, the couple underwent significant counseling emphasizing lifestyle changes to manage infertility caused by polycystic ovarian syndrome (PCOS). Following ovarian stimulations for oocyte retrieval, 17 oocytes were retrieved, and eight were of Metaphase II. Six zygotes formed after performing an ICSI. They expanded into blastocysts, and further blastocysts underwent cryopreservation. Later, with progesterone support, the frozen embryo transfer was performed, resulting in a successful pregnancy. After embryo transfer, the female patients underwent regular follow-ups to monitor the possible complications of pregnancy. This case report demonstrates the potential challenges and success of ART employing PCOS patients, despite previously unsuccessful IUI and ICSI attempts and the presence of hormonal imbalances. The utilization of controlled ovarian stimulation, ICSI, FET, and lifestyle modifications worked effectively to achieve positive outcomes in pregnancy. The case study highlights the significance of individualized treatments and guidance in managing infertility caused by PCOS. The significance of routine follow-ups in ensuring the health of both the mother and the fetus, that shows PCOS patients, can have successful reproductive outcomes.

INTRODUCTION

Infertility is a major concern globally, affecting millions of couples. Several factors can cause infertility, such as uterine polyps, fibroids, and thin endometriosis, among these polycystic ovarian syndrome (PCOS) is one of the major causes of infertility.[1] An abnormal uterine structure, tubal blockage, ovarian dysfunction, or genetic abnormalities can contribute to infertility in women. On the other hand, testicular or ejaculatory dysfunction, hormone imbalances, or genetic disorders may all lead to infertility in men. Infertility is defined as inability of a couple to conceive after one year of consistent unprotected sexual intercourse as infertility.[2] PCOS is considered an endocrine disorder that affects the reproductive years of women, this syndrome causes infertility, obesity, cardiac diseases, and insulin resistance. PCOS may also result from poor choices of lifestyle, it is a multifactorial inflammatory, uncontrolled steroid state condition.[3] It is one of the primary causes of ovulatory infertility in women and the most prevalent endocrine disorder affecting reproductive-aged women with a prevalence ranging from 8 to 13 percent based on the demographic examined.[4] To treat infertility in patients with PCOS, numerous therapeutic procedures are available, such as in vitro fertilization (IVF) and controlled ovarian hyperstimulation (COHS); however, many patients fail to conceive even after using standard infertility treatments, due to immature oocytes.[5] PCOS is considered as an essential component in women’s metabolic syndrome, a condition characterized by insulin resistance and hyperlipidemia.[5] The most challenging aspect of comprehending PCOS is hyperandrogenism, abnormal GnRH pulsation, inappropriate gonadotrophin production, and insulin resistance are all associated with the pathogenesis of PCOS.[6] According to the various criteria, PCOS has been diagnosed, including National Institute of Health Criteria 1990, Rotterdam Criteria 2003, 2006 Androgen, and 2007 Japan Society of Obstetrics and Gynecology.[6] The number of retrieved oocytes differs from the count of follicles aspirated, the patient with higher expectance for oocyte retrieval infrequently obtains fewer oocytes.[7] Ovarian disruption frequently associated with PCOS leads to inadequate oocyte competence for fertilization. The combination of androgen excess in PCOS patients and intrinsic molecular abnormalities in the oocyte is most likely responsible for these alterations in oocyte development.[5] Environmental factors and genetics also influence the development of PCOS. Several morbidities have been associated with the syndrome, such as eating disorders, type 2 diabetes mellitus, obstetrical challenges, infertility, and cardiovascular disease.[8]

CASE PRESENTATION

Patient information and medical/surgical history

After six years of marriage, a couple from the Maharashtra region visited the Wardha test tube baby center. A 35-year-old man and a 33-year-old woman had been trying to conceive for the past four to five years. The female was diagnosed with PCOS. They also had a previous history of one failed intrauterine insemination (IUI) cycle and one failed intracytoplasmic sperm injection (ICSI) cycle.

Investigations

The male partner underwent a semen analysis, a semen sample was collected in the laboratory. The semen parameters were reported to be normal according to WHO criteria. The total sperm count was 40 million per ejaculation, progressive motility was 50%, and additional semen analysis is shown in Table 1.

Table 1.

Semen parameters of male partner

Parameters of semen	Clinical findings	Reference ranges according to WHO
Volume of semen	2 ml	≥1.5 mL
Sperm count/ejaculate	40 million/ml	≥39 million/ml
PH of semen	7.0	≥7.2
Morphology of sperms	60%	≥4% normal forms
Motility of sperms (PR + NP)	52%	≥40%

The parameters of female hormonal investigations showed that the luteinizing hormone (LH) value was elevated to 12.2 IU/L, while the normal range should be 1.5–8.0 mIU/mL. The follicle-stimulating hormone (FSH) was within the range of <7 mIU/L, with a normal range of 1.5–12.0 mIU/mL, the testosterone level was elevated at >0.6 ng/mL, and the anti-mullerian hormone (AMH) level was also elevated 6 ng/mL (reference range: 1–4 ng/mL).

Therapeutic interventions and follow-ups

The couple received counseling on the impact of PCOS on fertility and the importance of lifestyle modifications including a balanced diet and consistent exercise. Prior to the stimulations, informed consent was obtained from the patient. On the 2^nd day of the cycle, baseline sonography was performed, and ovarian stimulation with purified urinary human menopausal gonadotrophin (HMG) or recombinant follicle-stimulating hormone (FSH) was initiated. The patient was advised to take a combination tablet containing coenzyme Q10, dehydroepiandrosterone, and melatonin once a day, as well as a combination pill containing alfacalcidol 0.5 μg and astaxanthin 8 mg once daily, follicle maturation was carried out by administering 0.2 IU decapeptyl and 5000 IU HCG (human chronic gonadotrophic) or 0.2 mg of leuprolide as presented in Table 2. Following ovum retrieval under transvaginal ultrasonography, a total of 17 oocytes were retrieved, out of them eight were of Metaphase II (M2), five of Metaphase I (M1), and four of germinal vesicle (GV) phase. On the same day, denudation and intracytoplasmic sperm injection (ICSI) were performed using a freshly ejaculated semen sample of the male partner. The fertilized oocytes were cultured in culture media for the growth of blastocyst. After 17–18 hours of fertilization, pronuclei formation was assessed to evaluate the fertilization outcome. Out of eight fertilized oocytes, only six zygotes formed and progressed through the cleavage stage to reach the blastocyst stage on the fifth day. Blastocysts were graded as per Gardner’s grading system. Best-quality embryos were cryopreserved for future use. Later, frozen embryo transfer was performed. Post-transfer, the patient received progesterone support to promote implantation and pregnancy maintenance. Pregnancy was confirmed with serum beta-HCG levels 14 days after transfer, followed by an ultrasound to assess the gestational sac. Continuous follow-up was planned to manage potential complications during pregnancy, with particular attention to gestational diabetes and hypertension, optimizing the chances of a successful outcome while minimizing PCOS-related risks.

Table 2.

Interventional medicines prescribed to the female partner

Name of medicine	Doses	Genetic name	Route of administration
Coenzyme Q10, dehydroepiandrosterone (DHEA), melatonin	Once in a day	Coenzyme Q10, DHEA, melatonin	Oral
Alfacalcidol (0.5 µg), astaxanthin (8 mg)	Once in a day	Alfacalcidol (0.5µg), astaxanthin (8 mg)	Oral
Human menopausal gonadotrophin (HMG) or Recombinant FSH	Day 2 of the cycle	Menopausal gonadotrophin (HMG) or recombinant follicle-stimulating hormone (FSH)	Injection (subcutaneous or intramuscular)
Decapeptyl	0.2 IU	Triptorelin	Injection (subcutaneous)
Human chorionic gonadotrophin (HCG) or leuprolide	5000 IU HCG or 0.2 IU	HCG (5000 IU) or leuprolide (0.2 mg)	Injection (subcutaneous or intramuscular)
Progesterone	1	Progesterone	Injection (intramuscular)

DISCUSSION

The report indicates that the use of GnRH antagonists is now a widely acknowledged approach for triggering oocytes in patients with a higher ovarian response and a high risk of OHSS.[9] One of the major factors contributing to PCOS is abnormal GnRH secretion from the hypothalamus. The pituitary secretes LH and FSH under the influence of GnRH. These two hormones are very crucial for some stages of the menstrual cycle.[3] PCOS is a leading cause of infertility among women of reproductive age. It is well established that infertility in women of childbearing age can be affected by infertility due to polycystic ovary syndrome (PCOS) which results from hormonal dysfunction, such as hyperandrogenism, insulin resistance, and inappropriate gonadotroph-releasing hormone (GnRH) pulsatility.[10] These disruptions consequently lead to ovarian dysfunction where the affected women may not ovulate at all or experience irregular ovulation. In this case, luteinizing hormone (LH) and anti-Mullerian hormone (AMH) levels were raised, which are associated with PCOS and lead to infertility.[11] Lifestyle changes and assisted reproductive technology were the most used treatment approaches in managing the condition. Dietary modification and exercise play critical roles in the management of PCOS since they increase insulin sensitivity and suppress androgen production, thus improving fertility in affected women.[12] Pharmacological interventions include the administration of gonadotropins, such as human menopausal gonadotropins (hMG) and recombinant follicle-stimulating hormone (FSH) for ovarian stimulation.[13] However, it was crucial to control and monitor the cycle because PCOS patients are susceptible to developing OHSS.[14] The collection of mature oocytes and subsequent fertilization through ICSI proved that COHS can counteract the impact of PCOS and lead to conception.[15] However, some problems are still questionable in handling PCOS, especially concerning oocyte quality and the rates of fertilization, as the hormonal conditions of PCOS influence them.[16] With the increased risk of pregnancy complications, such as gestational diabetes and hypertension in PCOS patients, vigilant follow-up is crucial.[17]

CONCLUSION

This case report highlights the case of PCOS, a significant cause of infertility in women due to hormonal imbalance (elevated levels of AMH, LH), which was managed with lifestyle modifications. Assisted reproductive technologies, such as controlled ovarian hyperstimulation and intracytoplasmic injection, are the most effective treatments for PCOS-related infertility. Following cryopreserved blastocysts were transferred, this cycle achieved a successful pregnancy despite prior unsuccessful attempts. Pregnancy was continuously monitored by taking regular follow-ups. Follow-up was suggested to evaluate pregnancy problems, including gestational diabetes and hypertension, ensuring a safe pregnancy while treating PCOS concerns.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.