I have PCOS. I am a very good responder to fertility medications such as Clomid. I'm scheduled for my first IVF in the upcoming weeks. I was told I am at high risk for hyperstimulation. How can I help keep this from occurring? I've heard I should drink water or Gatorade. Is one better then the other? How much water and/or Gatorade should I drink? I've been given a prescription of 10,000 of hCG. Is this too much? My initial prescription was for 5,000, so now I'm concerned that they really did want only 5,000.

S.A.

Women with polycystic ovary syndrome (PCOS) who receive ovulation induction injections are at greater risk for cycle cancellation or hyperstimulation. If the estrogen level rises too rapidly or there are too many eggs, as often the case for PCOS women undergoing IVF, the chance of hyperstimulation may place the women at risk for complications. Pelvic pain and swelling, shortness of breath, blood chemistry abnormalities and thrombosis are particular problems when hyperstimulation is severe.

While lowering the dose of hCG is often recommended, there are no studies that show that this will lower your risks. And, while maintaining adequate fluid input is important, this is not likely to prevent any of the side effects that may occur.

Hyperstimulation is not your only concern. The insulin resistance that often occurs with PCOS may affect other factors that can interfere with your IVF cycle. First, increased insulin production is associated with elevated male hormone production. Excess male hormones such as testosterone, androstenedione and DHEAS may interfere with normal egg development. Excess insulin may also increase various blood-clotting factors, PAI-1 in particular, which may interfere with blood supply to the developing follicle and the uterine lining.

As we continue to learn more about the association between insulin resistance and PCOS, we are seeing more and more patients who benefit from considering treatment with an insulin-lowering medication such as metformin, pioglitazone or rosiglitazone. These medications can frequently restore normal ovulatory cycles that occur one egg at a time.

Insulin-lowering medications are an important option that should be considered for all women with PCOS before trying injectable ovulation induction medications. As metformin costs $50-60 each month, I would certainly recommend that you consider this option, assuming PCOS is your only fertility problem. Be aware that this is a quite recent advance and as of yet, most physicians have little experience managing PCOS with insulin-lowering medications.