A more aggressive regime to stimulate ovarian function is to administer exogenous human gonadotrophin combined with the use of human chorionic gonadotrophin (HCG) to induce ovulation. This therapy may be used in conjunction with intra-uterine insemination of with IVF treatment. Both forms of treatment will require ultra-sound monitoring in order to assess follicular growth as ovarian hyper stimulation, and thus multiple ovulation, can occur. Treatment protocols for IVF vary from unit to unit but generally a period of 'down regulation' using gonadotrophin releasing hormone (GnRH) agonists are administered to prevent any release of LH from the pituitary. Endogenous FSH production is largely prevented by down regulation, so exogenous FSH is given to stimulate follicular growth and HCG, a protein similar to LH, is given to induce ovulation. Luteal support is essential as GnRH agonist therapy interferes with LH production and the corpus luteum will not function effectively.

Once a diagnosis of Polycystic Ovarian Syndrome has been made and treatment options discussed, the couple may choose not to have any further treatment and either seek advice from health professionals regarding adoption or fostering or remain childless. In Monarch's study (1993), eight couples (27%) withdrew from investigations and treatment. All these couples had very close contact with their families and therefore had a good source of social support. For many couples this support would be crucial at a time when they may be abandoning all hope of having a child.

Due to the complex nature of Polycystic Ovarian Syndrome, women are at risk from the condition in a number of ways which may require further long term planning and management. Firstly there is an association with increased insulin resistance, which may lead to a disturbance of glucose metabolism and therefore the development of diabetes.

Persistent anovulation and amenorrhoea can cause endometrial hyperplasia, and as Helmerhorst and Helmerhorst (1991) indicate, various studies have linked Polycystic Ovarian Syndrome to endometrial carcinoma. High levels of oestrogen in women with Polycystic Ovarian Syndrome arise from the conversion of androgens to oestradiol in peripheral adipose tissue. Obesity in women with Polycystic Ovarian Syndrome further enhances this conversion, and hyperoestrogenaemia may lead to a higher prevalence of breast disease (Coulam C.B et al., 1983). It has also been reported that women with Polycystic Ovarian Syndrome are at risk of cardio-vascular disease due to an unfavourable lipo-protein (Wild et. al., 1985).

It seems clear therefore that once a diagnosis of Polycystic Ovarian Syndrome has been made, adequate advice should be given and information made available regarding all these long term health issues.

Studies have shown that most men and women expect to have children and become parents at some point in their lives. (Michaels, 1988 and Phoenix, Woolett and Lloyd, 1991) and as Monarch (1993) points out, our society is pronatalist. Motherhood is seen as providing an identity for women and this gives them status. Parenthood is assumed and encouraged within society and both the media and the advertising industry consider it to be the norm. As discussed previously, women with Polycystic Ovarian Syndrome are often obese and media images of slim, attractive and fertile women may serve to heighten any feelings of guilt and loss of self esteem they may have.

Every woman reacts differently to a diagnosis of infertility but as Wills (1996) highlighted, many feel that their is "something wrong with them" and they may therefore feel stigmatised and socially isolated. More women are delaying becoming parents as they choose to develop career opportunities and difficulties may develop within their relationship when infertility is diagnosed due to feelings of guilt associated with this delay. When confronted with infertility either partner may also fear rejection. Equally couples may improve their levels of communication and understanding and their relationship may become strengthened. Sexual problems are commonly reported whilst undergoing investigations and may be caused by feelings of pressure to perform. This need to perform may be more essential than the need for closeness and affection, and feelings of resentment and shame may develop.

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