2. Weight reduction and ovulation induction

Scientific studies have not confirmed that women could regain spontaneous ovulation with voluntary weight loss and other life style modifications as systematic reviews did not identify studies that confirm that ovulation and other clinical reproductive outcomes improved with weight loss in women with PCOS but the studies identified increased total testosterone, androgen index, hirsute, fasting blood glucose, fasting insulin, and worsened lipid profile in the obese women compared with normal weight women with PCOS [7–9]. Obesity is linked to anolution and pregnancy loss as well as poor response with ovulation induction methods such as clomiphene citrate, gonadotropins, letrozole, and ovarian drilling [10–15]. This is important as previous authors have surmised that since obesity is found in some women with PCOS and worsens insulin resistance, that weight loss would improve ovulation and other reproductive outcomes [4, 16–19].

The American societies studying PCOS indicate that weight loss is a primary therapy in PCOS. That weight loss as little as 5–10% of body weight can regularize menses and improve response to ovulation induction and fertility medications [9, 12].

In many countries, lifestyle intervention is recommended as this has led to higher spontaneous ovulation rates and natural conception rates [20, 21].

Weight reduction through dietary modification and exercise is recommended for overweight PCOS patient [22]. Some studies show that over 10% of women with PCOS will regain spontaneous ovulation when placed on low calorie, low-fat diet, and exercise or with surgery. The aim of dietary restriction and exercise is toward losing about 5–10% of their body weight. This form of treatment alone or in combination with pharmacologic agents would reduce insulin resistance and is advocated for overweight to obese women of BMI > 24 [22]. The drawbacks of this method of treatment are that such women lack the motivation to remain on diet and exercise, and may not be able to achieve the desired weight loss to trigger spontaneous ovulation, and most times pharmacologic agents are added to assist ovulation. The duration it takes to achieve the desired body weight to bring about ovulation is not defined, but differs among patients. Other drawbacks are that it may not treat anovulation in normal-weight women even though they also have insulin resistance as well. The advantage is that it is cost-effective and will not produce any form of drug reactions. It will also reduce the high level of luteinizing hormone and reduce early pregnancy loss. A combination of lifestyle modification with weight loss before pharmacologic ovulation-inducing agents improved ovulation and live birth in women with PCOS in a USA study [23] and in addition, required lower doses of pharmacologic agent for ovulation induction.
