Frequency of Polycystic Ovarian Syndrome in Infertile Women Presenting at Mardan Medical Complex

Infertility is a common problem among women. It has been defined as the inability to conceive after regular unprotected sexual intercourse for a given period, usually a year.1 This condition has been a major medical and social problem due to its potential to cause emotional distress, psychological upsets, and social pressures on women and their partners.2 Female infertility can result from ovulation disorders, hormonal imbalances, uterine anomalies, and tubal blockage.3 The exact cause of infertility, however, can be difficult to identify. It can be the result of a combination of factors, including age, lifestyle, and medical problems.4

Infertility among women is caused by a variety of factors that are mostly complex, combining physiological and environmental factors.5 Disorders of ovulation represent a very common cause of female infertility, defined by ovulation failure to discharge a mature ovum on a regular basis, which presents with irregular or absent menstrual cycles.6 Hormonal disorders, such as an imbalance of estrogen, progesterone, luteinizing hormone, and follicle-stimulating hormone, can interfere with normal reproductive cycles.7 Other factors that lead to female infertility include endometriosis, pelvic inflammatory disease, uterine fibroids, and anatomical abnormalities of the reproductive system.8

Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders seen in infertile women, which is associated with anovulation, hyperandrogenism, and polycystic ovarian morphology.9 PCOS sufferers often experience irregular menstrual cycles, hirsutism, acne, and decreased fertility.10 Although the exact cause of PCOS is not well understood, this disorder is clearly related to insulin resistance and hormone imbalances, particularly an increase in androgens.11 PCOS impacts ovarian function, causing anovulation or impaired follicular development which is associated with decreased fertility. PCOS is also associated with metabolic problems, including obesity, diabetes, and cardiovascular disease, which further contribute to fertility problems.12 A study reported the frequency of polycystic ovarian syndrome in infertile women was 58.7%.13

There is a strong need to carry out this research in Mardan, considering that infertility is a pressing health issue that is surfacing as a significant health problem among women, with little information on its etiologies and patterns in this region. Polycystic ovarian syndrome is a common condition that is often seen in infertile women, though little is known about this condition in this region. Cultural factors, delayed health care-seeking behaviors, and lack of knowledge may further worsen health outcomes for women in this region. Therefore, this study was carried out to determine the burden of polycystic ovarian syndrome among infertile women.

The findings of this study revealed that PCOS was present in 89 (61%) of infertile women which indicates high prevalence of this condition among infertile population. This high frequency can be attributed to fact that PCOS is one of most common endocrine disorder affecting women of reproductive age and it directly interferes with ovulation process leading to anovulation or irregular ovulation which ultimately results in infertility. The study demonstrated significant association between age and PCOS with higher prevalence 38 (71.7%) in patients >30 years compared to 51 (54.8%) in patients ≤30 years with p-value of 0.045. This finding suggests that increasing age may worsen hormonal imbalances and metabolic disturbances associated with PCOS, as prolonged exposure to hyperandrogenism and insulin resistance tends to accumulate with advancing age leading to more pronounced manifestations of syndrome. BMI showed highly significant association with PCOS as 73 (68.9%) patients with BMI >25 kg/m² had PCOS compared to only 16 (40.0%) patients with BMI ≤25 kg/m² with p-value of 0.001. The high level of association can be explained through the mechanism whereby obesity results in insulin resistance, leading to hyperinsulinemia. This results in the production of ovarian androgen hormones while simultaneously decreasing sex hormone-binding globulin (SHBG) levels, thus increasing free testosterone levels in the body and worsening PCOS symptoms. The association between diabetes and PCOS was highly significant, whereby 25 (75.8%) out of 64 diabetic patients had PCOS compared to 64 (56.6%) out of 113 non-diabetic patients (p = 0.048). This can be explained through the pathophysiological mechanism whereby insulin resistance results in hyperglycemia while simultaneously affecting ovarian function through hyperandrogenism and irregular menstrual cycles, thus causing PCOS, a condition that results in infertility in women.

The frequency of PCOS in infertile women was found to be 89 (61%) in present study which is comparable to findings of Patil et al. 14 who reported 54.9% prevalence among infertile women but higher than Eleawi et al. 15 who found 29.0% (174/600), Oriji et al. 16 who reported 16.7% (29/174), Haq et al. 17 who found 17.6% (508/2884), and Hanifa et al. 18 who reported 49.5% (92/186). This variation in frequencies can be attributed to differences in diagnostic criteria used, study population characteristics, and geographic variations in prevalence of metabolic disorders. However, all studies confirm that PCOS remains major contributor to infertility affecting significant proportion of women seeking fertility treatment. Present study showed significant association between age >30 years and PCOS with 38 (71.7%) patients having PCOS compared to 51 (54.8%) in patients ≤30 years (p=0.045) which contradicts findings of Eleawi et al. 15 who reported higher prevalence in younger age group 20-29 years with 55.2% (96/174) and Hanifa et al. 18 who found no significant association between age and PCOS (p=1.000). This discrepancy may be explained by fact that in some populations younger women presents earlier for infertility evaluation while in other settings older women with prolonged exposure to metabolic dysfunction develops more pronounced PCOS manifestations leading to infertility at later age. The present study demonstrated highly significant association between BMI >25 kg/m² and PCOS with 73 (68.9%) patients having PCOS compared to 16 (40.0%) in patients with BMI ≤25 kg/m² (p=0.001) which is consistent with findings of Oriji et al. 16 who reported BMI >25 in 90% of PCOS women compared to 72% in women with normal ovaries, Haq et al. 17 who found obesity rate of 68.5% with 39.7% having BMI 25-29.9 and 28.8% having BMI >30, and Patil et al. 14 who reported mean BMI of 27.24±2 with 28.57% (16/56) having BMI 26-30 kg/m² and 19.6% (11/56) having BMI 31-35 kg/m². However, Hanifa et al. 18 found no significant association between BMI and PCOS (p=0.557). The strong association between obesity and PCOS in most studies supports pathophysiological mechanism where excess adipose tissue promotes insulin resistance and hyperinsulinemia which triggers ovarian hyperandrogenism and anovulation. The present study found significant association between diabetes and PCOS with 25 (75.8%) diabetic patients having PCOS compared to 64 (56.6%) non-diabetic patients (p=0.048) which aligns with findings of Haq et al. 17 who reported abnormal insulin levels in 59% of PCOS patients and family history of diabetes in 54% cases. However, Eleawi et al. 15 reported lower prevalence of diabetes mellitus in PCOS cases with only 2.3% (4/174) compared to 1.4% (6/426) in non-PCOS group. This difference may be related to different diagnostic criteria for diabetes or different stages of disease progression in study populations where some patients may have insulin resistance without overt diabetes while others already developed clinical diabetes.

The limitations of the current study are discussed below. The current study has a limitation because it was conducted at a single center. This might limit the study’s representation of the entire infertile community because the characteristics and patterns of patients attending different healthcare settings might differ. Secondly, the current study was based on a small sample size, with only 146 participants. This might have limited the representation of the entire infertile community. Thirdly, the current study design was a cross-sectional study. This limitation meant that the current study was not able to examine the longitudinal associations between PCOS and other factors.

The study concluded that the prevalence of polycystic ovarian syndrome (PCOS) is high among infertile women and is a major factor of female infertility. The study revealed that PCOS is associated with increasing age and high body mass index. This implies that metabolic factors are important in the development and progression of PCOS.

Disclaimer:

Nothing to declare.

Acknowledgment:

The author wants to thank the hospital medical teams. Their help in keeping patient file and handling data properly made this study possible.

Ethical Permission:

Permission for this research was taken from the ethical board. All step of the study was done by following committee instruction and rule of Helsinki Declaration.

Patient Consent:

Consent in written form was taken from all patient before study start. Patient were informed that their data will be confidential and they were free to stop participation whenever they want.

Conflict of Interest:

Author confirm there is no personal or financial conflict related to this research.