OGSSI PCOS / PMOS

[00:00:00]Yes, >> good evening esteemed faculty members and all the delegates. Thank you for joining. This is Sahiti on behalf of Shil Kanet. Welcome you all for today's webinar PCOS or PMOS organized by Oxy.

[00:00:13]So it's my privilege to introduce the MOC of today's webinar. Uh Dr. Angelina Ma is junior consultant in motherhood hospitals Alva Chennai. Ma'am has served as the missionary doctor in rural tribal Christian mission hospitals in northeast India and also speaker in multiple conferences like refresh SRMC and Cox AL conference during her PG. I welcome you ma'am and I handle the session to you.

[00:00:41]>> Uh yeah uh thank you for that kind introduction and before I start I'm grateful for this opportunity to MOC this event and to present the journal.

[00:00:50]Uh good evening esteemed Oxy members, faculty and dear prograduates. I warmly welcome you all to the Oxy Research and Quiz Committee flagship event quer Scientium online journal club and quiz.

[00:01:03]Our topic today will be the hottest and the most talked about PCOS. Oh wait, sorry POS from the PCOS to the POS from the cyst to the metabolism. This is the biggest discussion in reproductive medicine today and we at Oxy are right at the middle of it. PCOS is trending not only on Instagram but on every journal, guideline and conference this year. For the past 30 years, we've called it polycystic ovarian syndrome.

[00:01:30]But now the big question in town is uh what is the need to rename it or rebrand it to PMOS, polytabolic ovarian syndrome. And tonight we're going to talk about it, debate it and quiz on it.

[00:01:43]To start the evening, I request Dr. Deepa Tangamani Ma'am for the welcome address. She is she's the consultant in Apollo First Med Hospitals Chennai. Her special interests are gyneic endoscopy emergency obstitics and intrapartum care AR art. She's secretary ATRC and executive committee Oxy and chairperson in Oxy 2024 and clinical examiner for a part MRCOG. Over to you ma'am.

[00:02:09]>> Thank you. Thank you Angeline. And uh once again good evening uh one and all who joined here and a warm welcome to each each one who are joined. At the outset I would like to thank our oxy president Dhana madam. Um because of Dhana madam there are lots and lots of of youngsters and other peoples are joined into the society. We call that as a nexus community and we have uh we are growing uh with lots of young population. He's a brainchild of Dhana madam. Uh so I thank once again for that. Uh and then I would like to thank uh Sumati premanand the treasure as well as Malaraj and today's as Angelina has briefly described is PCOS with PMOS and what whatever the basic pathology as well as the what the fight is going on in the regarding the name change and we have a funny quiz at the end. Thank you.

[00:03:03]Over to you Angeline.

[00:03:06]Thank you ma'am. Now we will begin with oxy prayer. I request Dr. Priya Kanapan ma'am to lead us. Uh she's a senior consultant Dr. Ma Hospital and GFC fertility center Chennai. She's the executive member Oxy since 2021 co-chairperson Oxyquist and clinical research committee Foxy committee conductor coordinator for Tamil Nadu and master trainer in Foxy HPV vaccination.

[00:03:28]Over to you ma'am.

[00:03:30]>> Thank you.

[00:03:32]So it's a privilege to host this meeting. So I'll go ahead with the oxy prayer. Thank you God. In humility we gather. In gratitude we pray for all the good things you have given us. Shower us with your blessings. To pass on the healing touch. To celebrate the arrival of new every new life and the mom reborn. The courage to deal with it all when things are not perfect and to remember that we are but messengers. To keep our women safe and free from sorrow. We bow before your kindness and the magnanimity of your endless love.

[00:04:06]Thank you.

[00:04:09]>> Thank you ma'am. Uh I request uh Deepa ma'am to introduce the moderator and presenter.

[00:04:19]>> Thank Dr. Deepa's help.

[00:04:20]>> Sorry. Yeah. Yeah. Sorry. Okay. Uh I I next we'll move on to the first session.

[00:04:25]The first session is a journal club discussion. I already shared the journal in most of the uh WhatsApp group and to moderate this journal to uh the journal cup discussion will be done by Dr. Angelin Emanuel and she has been uh introduced earlier by our uh platform u person Dr. Mr. Sakit and I one thing I want to uh tell she is an MBA holder in hospital management from bitsani that's a surprising thing from Angeline for me it's a surprise thing and you also got a gold medal in Sri Ramachandra medical college puru congratulations and she did a fellowship in minimal access surgery and the the whole general cup discussion will be moderated by um madam um madam is nana um she is Our long-term and all research activities is one or to be remembered for the last five six years since we taken over the research committee and most of her paper and poster she is a judge and she is a voracious she's a great teacher and she's very popular among postgraduation postgraduate students and she is a thesis instructor for many students and uh she is from Sundra medical foundations foundation chennai she's a departmental uh uh department of obsidic energy. His madam is a senior consultant. She is also a member of various societies. He presented many papers and posters. Madam is a faculty in PG division courses and conferences in oxy and almost all courses of Ramachandra. Madam special interest is highrisisk obsetics endoscopy and academics and madam is going to moderate the debate as well as this general cler. Over to ma'am.

[00:06:10]>> Thank you Deepa for the kind introduction. Thanks Dr. Priya uh we have had a very enriching relationship over the years. So thanks for it. Let's hope the session teaches us all.

[00:06:24]Shall we go on with it?

[00:06:26]>> Yes ma'am.

[00:06:30]>> So Angeline you can share the slides.

[00:06:32]>> Yes ma'am.

[00:06:46]Is my slides visible?

[00:06:47]>> Yes.

[00:06:50]>> Uh so uh let's start the journal presentation. Good papers don't just change practice, they change patients lives. The journal paper for today is lifestyle intervention before and during fertility treatment in women with obesity or with overweight and PCOS. A randomized control trial conducted by Matia Balan and at all uh in the research center of the center hospital air derbuk crus sherbrook in Canada and was published in the journal of clinical endocrinology and metabolism in 2026.

[00:07:28]So a little background on the whole article. Uh in Canada approximately 10 to 15% of the couples are infertile and 24% of women aged 18 to 44 have a BMI of 25 to 29 and 22% have a BMI of more than 30. Basically almost 1/4 are obese in Canada are overweight or obese in Canada. A study already said that 4% decrease in consumption rate. um there was a 4% decrease in consumption rate for every 1 kg per meter square increase in BMI between 30 to 35 and we already know that pre-preg obesity will lead to gestational diabetes preeacclampsia increased cesarian delivery rates and intrauterine death and other adverse effects. Many guidelines have already recommended um recommended as a first sign treatment that women with obesity should be assisted before conception to lose 5 to 10% of their initial weight.

[00:08:27]So the objective of the trial is structured lifestyle programs are not a part of routine fertility care nor integrated in most fert fertility clinics. Basically we do have fertility counseling which is done by the consultants the fertility specialists as such but there are no structured lifestyle programs that are happening by uh specialist um dieticians and exercise therapists basically. Uh so these structured lifestyle programs are not part of routine fertility care nor are they integrated into most fertility clinics in part because there is still a lack of RCTs assessing their effectiveness of lifestyle programs in women with obesity and infertility. So the main object of the study was to determine the impact of the obesity fertility lifestyle program on fertility outcomes of women with obesity and subfertility seeking care at a fertility clinic. This is a RCT uh done at a fertility clinic in the uh CHUS hospital in Canada. So the inclusion criteria were all infertile women aged between 18 to 40 were included who had a BMI of more than 30 or a BMI of more than 27 for women with PCOS because they believed that women with PCOS showed metabolic risks and um risks uh at a younger BMI at a lower BMI of 27 kg per meter squared. And uh women were considered infertile if they for if they uh were not able to conceive after one year of more or more of irregular and unprotected sexual intercourse for women under 35 years which we already know and after 6 months for women between 35 to 40 years of age or if they had irregular menstrual cycles or if uh they had a previously known cause of infertility.

[00:10:11]Exclusion criteria we excluded women if natural conception was impossible or highly unlikely. For example, if both the tubes are blocked, then how much how much of a weight loss we do? Obviously, they're not going to get conceived. Uh or if the partner's total motile sperm count was less than 5 million, which is basically severe male factor infertility. Or if they had undergone our plan undergo beriatric surgery because the beriatric surgery as such would give better fertility outcomes and not our program. So that's why they were excluded.

[00:10:41]The eligible women were randomized in one is to one ratio to one of the two research arms with stratification for PCOS which means equal amount of PCOS patients were in both arms and owing to the nature of the intervention and the organization of re research team it was not possible to blind the participants or those delivering the intervention.

[00:11:00]Basically the participants will know that they're getting the intervention.

[00:11:02]It is impossible to blind the participants or the person giving the intervention because they also they'll also be aware that they're providing the intervention. So it was not possible to blind the study. So coming to the study as such uh there was an intervention group and there was a control group. So the intervention group received a ad hoc which is basically a customized six month lifestyle intervention. For 6 months they underwent lifestyle intervention after which they had fertility treatment if required starting after the six months in combination with lifestyle intervention. So 6 months of lifestyle intervention followed by fertility treatment if required and along with the fertility treatment they also received lifestyle intervention. So what was this lifestyle intervention?

[00:11:44]They basically uh received individual counseling with a registered dietician and a chinesiologist at 3 weeks postrandomization then every 6 weeks.

[00:11:54]The intervention also had 45 minutes of interactive workshop on topics relevant to obesity management, fertility and lifestyle habits and a 45minute physical activity session as well. After the first 6 months, non-pregant participants could begin the fertility treatment in parallel to the lifestyle intervention for up to 18 months. The period of study was a total of 18 months of participation or if they ended up getting pregnant then they no longer will need the lifestyle intervention.

[00:12:21]control group will receive the fertility treatment immediately. There is no lifestyle intervention in the control group and the fertility treatments were individualized according to their conditions. Like if they had PCOS, then based on that they'll be treated. The usual practice is they usually have ovulation induction done for three to six cycles. Then if not pregnant, they'll have three to six cycles of IUI and then go on to IVF. And usually it's less than three frozen embryo transfers.

[00:12:46]The standard fertility treatment may include lifestyle counseling by the patients fertility specialist. So the fertility specialist as such will give some sort of fertility ad I mean lifestyle advice but then uh uh it was not by professionals.

[00:12:59]The outcomes both the groups are followed for the total period of study of 18 months or until the end of pregnancy which is confirmed within the period of study of 18 months of randomization. So they look for live birth or miscarriage. Data collection was scheduled every six months. So if a patient is not pregnant they every 6 months data was collected but however if they got pregnant data was collected at the onset of pregnancy between 24 to 28 weeks and at the end of delivery. Um and medical records of participants and newborns were reviewed after the end of participation to document the clinical outcomes. So what is the primary outcome? What is the secondary outcome?

[00:13:33]The primary outcome was the rate of live births resulting for pregnancies which were confirmed within our study period and the secondary outcome was fertility outcomes like like clinical pregnancy.

[00:13:43]miscarriage, still birth and method of conception like uh did they conceive without treatment or did they use the ovulation induction with or without IUI, IVF or frozen embryo of IV, IVF with Ixie or frozen embryo transfer. The number of fertility treatment cycles were also measured and anthropometric measures like weight loss, fat mass and weight circumference was also measured.

[00:14:03]So these were the secondary outcomes. So sample size calculation they used a study done in 2011 uh an Australian RCD showing that 171 women with obesity and subfertility a fert fertility fitness program increased the 18month pregnancy rates from 21 to 61 which was 61% which was significant.

[00:14:24]So using this uh expecting the lifestyle intervention to triple the effect, we calculated a sample size of 58 women per group would provide a study uh would provide a study a power of 80%. 80% is usually the power that's used for RCTs in general to identify a doubling in the primary outcome rates. So basically the stat statistician said that if we had 58 women in each group then we would be able to identify doubling in the primary outcome and assuming a dropup dropout rate of 10% our final estimated sample size was 128 women.

[00:15:00]Uh before going into the discussion and results it's very important to understand three types of analysis in RCTs. So there's something called intention to treat. There's something called modified per protocol analysis and there's something called per protocol analysis. So an intention to treat analysis once randomized is always analyzed which means that if a uh if a person is analyzed under group A then even if he drops out or even if it's non-compliant he did does not follow the rules he gets crossed over he gets lost to follow up even then he will be analyzed under the same group and uh that is what is intention to treat. So if you see 100 patients are randomized, 50 goes into intervention, 50 goes into control. Even if they dropped out, they're non-compliant to our lifestyle intervention, they crossed over, whatever it is, they will still be analyzed. All 100 patients analyzed in the groups, they were originally randomized to they will not be excluded.

[00:15:50]So here what happens is this reflects the real world effectiveness because you this is what happens in the real world.

[00:15:56]We can't expect them to strictly follow all our protocols versus the per protocol analysis which is the complete opposite where it analyzes only those who completed the entire study as per protocol which means that only the person who followed the protocols did not drop out or did not cross over did not lost to followup throughout the entire period will be considered for analysis. So here uh uh basically this reflects the ideal conditions and in an ideal world this might work and uh this is more prone to selection bias. So this is not recommended as a primary analysis whereas intention to treat is recommended as a primary analysis. And the third one is the one in between which is modified per protocol analysis which is something like middle ground.

[00:16:40]It's neither too lenient like intention to treat neither is it too strict like per protocol analysis. It's something in between where it analyzes those who completed the initial intervention period which means patients who um were uh compliant in the first 6 months who did not drop out in the first 6 months and who did not were not lost to follow-up in the first six month were included. So it includes participants who completed the first 6 months uh shows effect among adherent participants and this has less bias compared to the per protocol analysis. So in our study they used the intention to treat analysis as well as the modified protocol analysis.

[00:17:20]Uh so 254 women were eligible at the end of the day of which 130 agreed to participate and were randomized. And so we had 65 on the intervention arm and 65 on the control arm of which two were excluded because they had severe male factor discovered after randomization.

[00:17:38]After randomization they found out that they had severe male factor and they couldn't include them in the study. So two are excluded in the intervention arm and one similarly was excluded in the control arm. So at and then we got a 63 and 64 as numbers to analyze based on intention to treat analysis.

[00:17:55]Then like we had already discussed those who uh in the first 6 months had lost to followup had withdrawn or no longer wanted children or ended up being separated with their partner were all excluded. These are people who did all of this in the first 6 months. So and also people who started fertility treatment before 6 months into the trial were also excluded because you cannot see the effectiveness of the six months of fertility treatment if they already started their fertility treatment before our trial even started. So in that way 12 were excluded from the control arm and seven were excluded from the sorry 12 were excluded from the intervention arm and seven were excluded from the control arm and we got a number of 51 and 57 for the modified per protocol analysis. So this was the numbers used for the NPP analysis. And finally uh for uh for analyzing the anthropometric measures or the weight loss we had to exclude few people who uh came too early for their visits. Basically if you see the first PV1 is the first protocol visit and V is the sixth protocol visit.

[00:18:56]So these were completed less than five months after randomization and uh or they were completed more than seven months after randomization. So we want them to come at 6 months or plus one month and not too early which is less than five months or too late which is more than seven months. At at more than seven months you're going to check the weight then you cannot analyze it and it might not be significant. So nine were excluded in such a manner and 14 were excluded in such a manner in the uh control group and at the end for the uh analysis of anthropometric measures 42 and 43 were the numbers.

[00:19:32]So coming to the results in uh based on the intention. So the results were one based on intention to treat analysis and two based on modified per protocol analysis. So first we'll see the intention to treat analysis.

[00:19:43]So uh coming to the anthropometric changes it was found that the intervention group uh having the lifestyle modifications and the program showed greater weight loss. they showed a weight loss of uh 3.14 kg compared to uh only4 kg in the control group. So that was significant p value of 0.01 uh 0.01 and the percentage weight loss was 3.21% in the intervention group versus the control group which was only 0.4 and that was also significant a p value of 0003. The bait circumference loss was also significant. Two cm in the uh intervention group versus 0.2 only in the control group and that was significant as well. The decrease in fat percentage was not significant. The fat mass was significant p value of 0.04 and a higher percentage of participants in the intervention group achieved at least 3% and 5% weight loss. Uh so these are the baseline characteristics of women in the intention to treat analysis. 63 in the intervention group and 64 in the control group and it was found that uh they did not display clinically important differences at baseline. So the education the smoking status the narly parity the BMI were all very similar.

[00:20:59]Coming to the primary outcome when analyzed in the intention to treat analysis if you see the first line intention uh intervention group had 28 live births and control group had 23 life births and this gave uh this if you see is uh more as in the intervention group does have more live births compared to control group but however the p value was only 0.3 so it was not significant the primary outcome was not significant uh similarly the clinical pregnancy rate was also higher 33 and 24 but however even then the p value was not significant. The miscarriage and the still births did not differ between the groups. Coming to the secondary outcomes, if you see the uh the again the first line natural conceptions, it was 17 in intervention group and eight in the control group and it has a p value of 0.049 049 which is uh significant and uh if you come to the uh there is no statistically significant difference between groups in the rate of clinical pregnancy after different fertility treatment methods but intervention groups seem to have higher rates of clinical pregnancy after IUI but still it was not significantly of 0.08 08. Then as per the modified per protocol analysis uh which is as we already discussed analysis where uh uh where the participants followed the protocols well enough but not completely. And uh so here if you see the baseline characteristics um showed no statistical difference between both the groups. All of them were almost similar. And coming to the primary outcome uh again the primary outcome in intervention group was 26 and control group was 21. although not significant there was a higher life birth rate in the intervention group compared to the control group p value was 0.1 not significant and the rate of clinical pregnancies however were highly significant uh which was a p value of 0.02 02 there was no significant difference in miscarriage or still births between the groups.

[00:22:56]Coming to the secondary outcomes uh the rate of natural conception was significantly higher compared to the control group 17 in intervention and control showed seven with a p value of 0.01 and it was also seen that the intervention group had 3.3 times higher rate of achieving clinical pregnancy using IUI but however it was not statistically significant. It was a p value of 0.05. 058 close to statistical significance and uh there was no significant difference between roots and use of fertility treatment including no fertility or uh the mean number of cycles per women.

[00:23:32]Uh so the coming to the strengths and the limitation the strength is it was an extremely pragmatic study which is meaning a very practical study. Uh an important strength of a study is that the lifestyle interventions provided continued into the fertility period as well. Like when they were trying trying the fertility uh treatments, uh the lifestyle interventions were also done during that period as well. And uh the quality of intervention was ensured by professional counseling from both chinesiologists for physical activity and a dietician for nutrition who were trained in motivational interviewing.

[00:24:05]The limitations however is the lack of statistical power to define uh definitively conclude differences in live birth rates. Basically we see that the live birth rates are higher uh in the intervention group compared to the control group but the numbers are not enough to say that they're statistically significant. Uh and that is one major limitation. The second limitation is that uh we are not able to blind the study. We are not able to blind the intervention but then this is how it is in real life. So uh so it's very pragmatic and it reflected real life. So it's okay and uh if you see in our MPP uh modified per protocol analysis um it's subject to non-random attrition which means that there is a loss of the participants who are not adherent to the intervention group. So because they were removed there this might have led to an overestimation of the treatment effects.

[00:24:54]However this also reflects the real life scenarios.

[00:24:58]So coming to the conclusion, a six-month lifestyle intervention alone subsequently combined with fertility treatments if required resulted in a non-significant increase in the 18month rate of pregnancies leading to life birth which is a primary outcome and a significant increase in the rate of natural pregnancies compared to the usual fertility care. Since the primary outcome of this trial was not met, more research needs to be done uh in a multic-enter RCT setting with appropriate statistical power. So the clinical implications are lifestyle intervention programs improve weight and natural consumption. It is proven that the way there was weight loss. It's also proven that the natural consumption rate increases. It reduces the need for art and the costs involved. So obviously if the natural consumptions are increasing, art will reduce. So we should consider integrating lifestyle intervention programs into fertility care. I think these days we just talk to the patients ourselves about losing weight and uh diet diet but a structured program where patient pay for the dietitionian visit and the kinesiologist visit would benefit them. Only lifestyle intervention programs does not delay pregnancy because we see that a group one group had only lifestyle intervention while the other group was undergoing fertility treatment. But still at the end of the day uh the group which underwent only lifestyle interventions uh ended up having a better pregnancy rate. Take-home message primary outcome live birth rate was not significant. Natural pregnancy rate was significant. Clinical pregnancy rate significantly increased in the MPP analysis and large multicentric RCTs are required. Thank you.

[00:26:46]Uh thanks Dr. Engine that was a very lucid and uh wonderful presentation. So now basically what did we Am I audible please? Yeah.

[00:26:57]>> Yes ma'am.

[00:26:58]>> Okay. So what was the main objective?

[00:27:01]What would you say was the main objective of the study? Why have we done it?

[00:27:07]The main objective was because there are not enough RCTs to prove that a fertility program would increase the conception rates or the life birth rates.

[00:27:16]>> So it was an obesity fertility and lifestyle program. Uh and it is assessing the fertility outcomes in women with obesity and subfertility and it was done at a fertility clinic. So it makes more sense because uh the same people who are dealing with fertility treatment have done this study. So they were able to achieve a better uh the results you know the results would make sense to them. Okay. So that was the question which we all had to answer here. Uh the main thing whether reducing the weight or changing their uh uh waist circumference fat loss would change their fertility outcomes. Now the primary outcome was mentioned as a live birth rate but our study did not uh show this right. It did not significantly increase a percentage of live birth rate but it did show it could increase right it was not significant but it did show the live birth rate was increased in the intervention group. Now how would you think this would help in our application of this in our fertility clinics? What how would you think we would go about it?

[00:28:25]uh ma'am so I don't think we have uh a lifestyle program as such like a six-month dedicated structured customized lifestyle program where patients are held accountable and asked to come every 3 weeks or six weeks where they are uh counseledled about diet because I don't think everyone's very confused now with social media everyone's saying different different things so I think if they have a u a visit every six weeks where they're held accountable on their diet and also thought the right exercises Then there is significant weight loss which does lead to significant increase in the fertility rates which we don't have right now. I think only the clinicians are counseling from their side saying try to lose weight go to a gym or try to eat healthy. So I think the structured program has proven that it will help and also if the natural pregnancy rates improve like how they have said in the study then the art rates will reduce so it'll be cost beneficial for the patients as well.

[00:29:20]>> Okay. Yeah. But would can we use the same cutff? The cutff here is given as 30 BMI 30 or more for the uh most of the women and those with PCOS 27 or more. Okay. So what how would we apply? See any paper which we need to discuss we have to make sure it is going to apply to our population as well.

[00:29:42]>> Right. We have to take it into our practice all the strengths of the study and try to incorporate it into our clinical practice so we do the best for our patients. Now here the cut offs for obesity would the same apply to our Indian population. What do you think about that?

[00:29:57]>> We need to uh we need to find the incidence of obesity in our population as well and then >> no cut off BMI cut off. What would you think? Would the same cutff be valid for our population or would you want to modify it to our Indian population?

[00:30:12]Asian what is the BMI?

[00:30:16]>> Ma'am 30 is obesity. Yeah, it will be more.

[00:30:19]>> Let us see. Huh? for Asian population or the Indian population >> Indian population >> the cutff is a little lower >> is >> cut off is at a lower is at lower so we have to use that for our population and then take into study so if we call obesity 30 no 27 20 25 onwards itself it would be considered as obesity for our Indian population and as you rightly said we do not have a protocol for obesity management in fertility clinic set up. Our patients are also in a hurry. The moment they come, they want treatment started. It's very difficult to tell them, explain to them that some amount of weight loss 3 to 5% 5 to 10%.

[00:31:04]Whatever is feasible every 1% weight loss is going to improve their yeah 25 kg. So it is going to improve our uh results. Okay. with a live birth rate and so but can we apply this you know treat uh first counsel them and then 6 months you go into this obesity program and then uh you know weight loss program and then come on for the further fertility management what sort of patient would you like to put into this group >> uh only patients who do not have severe male factor infertility or >> you ruled out those patients right >> yes ma'am So chosen your population for this uh weight loss management. Okay.

[00:31:48]>> Yes ma'am. So population who can naturally conceive uh we would uh include in this.

[00:31:55]>> So did you choose by age or anything?

[00:31:58]This doesn't do 18 to 40 years of age.

[00:32:01]They have taken an entire 18 to 40 years of age program. Right. So if a patient is coming at 35 they've included PCOS also at 35 or more and she's already having irregular cycles or maybe even elderly for you know closer to 40 then you have to consider that we cannot delay the conception protocol you know the fertility treatment we have to take it with um sort of less uh the low lesser age group they have enough time to get into this uh protocol and then go there is time for them but severely ly you know PCOS with extremely irregular cycles or the elderly patients after 35 years of age we may not be able to first give them a six-month program to lose weight and then go ahead with fertility treatment you have to consider uh start to uh starting fertility treatment alongside that encourage weight loss alongside that let them follow these lifestyle interventions it's a younger age group so it should not be a blanket call 18 to 40 we can put them all into the same protocol. 6 months go try and reduce weight and come back. Okay. So for certain patients you will have to do these lifestyle interventions alongside their fertility management. Okay. What else you said clinical pregnancy rate was increased. What is clinical pregnancy rate for just for the benefit of our PT students who are listening here?

[00:33:29]uh ma'am uh a live fetal heart rate seen on the scan uh is uh clinical pregnancy.

[00:33:37]>> So it does not necessarily mean the outcome right whether it ends up with a miscarriage or the live birth but pregnancy rate. Okay.

[00:33:46]>> And um what else would you want to do? any errors in this study that you would think it's present >> ma'am the >> what are the errors >> the numbers can be higher the numbers could have been higher then it could have uh probably proven a statistically important live birth rate statistically significant life birth rate as well >> yeah the power is much more the numbers could have been higher so future studies are important But there is a likelihood of a type two error. So what is a type two error? Have you heard of those errors?

[00:34:28]>> Yes, ma'am. False positive error.

[00:34:30]>> So why could there have been a type two error here?

[00:34:34]>> Uh because the uh the the power of the study is n uh is 80. If 80%, if uh if we increase the power of the study, then the type two error usually reduces. And uh >> yeah the number of patients would you you would need would be more if you want to reduce this we have assumed you know when the beginning of the study itself our assumption is 50% uh would show a primary outcome right >> rather than 25% parent article show 25%.

[00:35:10]>> The Australian study show 25%. we start assuming with a larger number. So probably the that would have led to our error as well. What about clinical implication then for these studies? We have already discussed how to go about it. But how would you interpret the study clinically?

[00:35:32]It says primary outcome is not significant here. That's what we were trying to look for. So fine, I don't it's doesn't matter anyway, right?

[00:35:41]patient losing weight but doesn't increase uh show a significant increase in the live birth rate. So it doesn't really matter. Let us just go ahead with fertility outcome. Would that would that be what you would interpret from this study?

[00:35:56]>> Uh ma'am from this study it seemed that the natural conception rates have increased.

[00:36:03]So uh so when when the obes when the uh BMI reduces the patient becomes more fertile and uh ends up having a natural conception.

[00:36:13]>> So they found no significant difference here but it was underpowered. So again that could have been the reason why it was not significant but it did show an increase in the live birth rate. It showed an increase higher clinical pregnancy rate in the intervention group and then weight loss everything was excellent in this group plus natural conception rates were far higher. So you could have avoided with the further fertility treatments. Should we just assume that lifestyle has no effect on live birth? No. What would you say that?

[00:36:44]How how would you label it as uh how would you like >> it may have lifestyle may have an increase in the life uh birth rate just that the numbers were not high enough to >> so not in this study but would you think how would you tell this to your patient >> um because uh usually if the fat percentage reduces or the amount of fat in the body reduces the central obesity atosity reduces then it'll uh help in hormone regulation. It'll combat with the hormone dysregulation and thus help in the increasing the pregnancy rates.

[00:37:22]>> Okay. Excellent. So even if it's not a major weight loss as shown on the scales, even a small amount of changes in this hormone imbalance is likely to give them a better outcome. So this is how you will explain to the patients who are obese and would want to plus it's not just limited to the six month period that we are studying across 18 months that they were being followed up. they had to continue the same lifestyle interventions and they got the uh results out of that. Okay. So that is one of the strengths of the study as well. It continued for 18 months. Though there were a few dropouts here, the persons who remained in the study throughout 18 months, they were continued to be um monitored in the study. Right? So it's extremely important that right now we are finding an increase in obesity in among our population. This particular cohort included both the PCOS as well as a non-PCOS right so obesity has adverse outcomes on fertility outcome as well as the uh pregnancy outcome. So that is the intention for treating them with lifestyle measures changes in lifestyle.

[00:38:28]So we need to address this population that is very important to go start with weight reduction which is what we do not do even if they come to us for preconception counseling that is where now uh the knowledge is much more among our uh younger gener younger reproductive age women. So they do come to us. We see a large number coming to us for preconception counseling. That is where we need to start addressing this.

[00:38:54]You know if you put it across from these studies if you it always gives enough uh more meaning to the intervention when you quote some studies or and then you tell the patient this is what happens.

[00:39:05]So if you start losing weight your natural pregnancy rates will go up conception possibilities go up. So we'll have to address that. And as you rightly said when a patient with fertility issues come to our clinic what do we do?

[00:39:20]Yes we do measure the BMI you we go we tell them go see the dietician start reducing weight start exercise but let's start ovelation induction and treatment at the same time. Yeah, for the younger population that older population this might help like we already said but the younger population ask them to first start and with changes in the lifestyle measures there's a lot of expense involved in fertility treatments so if you're able to achieve a natural conception with these lifestyle changes it would be better for our Indian population right so we cannot apply this study in large measure we cannot ask our people to go and meet a kinesiologist or a dietician and they include six weekly sessions.

[00:40:03]Yeah, we need to follow up. But the study according to the Canadian study, we cannot do the same to our population.

[00:40:09]Individual counseling, group counseling for over 12 uh 12 counseling sessions and then they have to pay all these people kind ofologists and all that. So we can have a multi-disiplinary treatment include them in a group but we may not be able to serve them as exact like they have done in that study. We have to model it for for our patients based on the costs involved. Followup is extremely important. They need to be motivated. You follow them up so that you are constantly motivating these patients. Okay. So this study is useful in that it just tells us lifestyle modification even if the small it's actually 6 months is a short period only right. So even short periods of lifestyle mod modification even if they lose a few kgs it goes a long way for a better reproductive outcome. Yeah that was wonderfully done. Thank you.

[00:41:09]>> Thank you madam such a wonderful discussion. So Deepa ma'am are you there?

[00:41:16]Deeper ma'am.

[00:41:22]Uh ma'am shall I take over ma'am?

[00:41:27]>> Yes please.

[00:41:28]>> Yeah. Uh so moving on to the session two. Uh it's a dialogue debate. Uh for decades polycystic ovarian syndrome has been one of the most common endocrine disorders affecting women in reproductive age group. However the name PCOS itself has been questioned in the recent years. The term polycystic is misleading because not all women have polycystic ovaries on ultrasound. This has led experts worldwide to propose a more inclusive term POS or polytabolic ovarian syndrome. The push for this change gained momentum after the 2023 international evidence-based guidelines which highlighted the metabolic basis of the disorder. Today's discussion is very timely because as clinicians it's important that we stay updated with evolving nomomenclature that impacts patient counseling research and public perception. To debate this and this for and against we have with us Dr. Priya Kanapan mam and Dr. Anit Kumar sir. Um Dr. Dr. Priya mam as we already know she's her she's a senior consultant in ma hospital GFC fertility center and um she's an executive committee member in oxy and co-chairperson oxyquist and clinical research committee foxyquist committee coordinator for Tamil Nadu and master trainer in foxy HPV vaccinations uh key achievements are best outgoing student best resident award for manipal university recipient of RCG traveling fellowship award and invited speaker in many national conferences um ma'am Uh now I'd like to introduce Dr. Anit S.

[00:42:55]Dr. VM Anit Kumar Sur is the MBBS PSG MSR MRC from UK Royal College London andology certified Cleveland Clinic USA MSOG from MMC and fellowship in reproductive medicine from Semar fertility coach diploma in reproductive medicine from KE University Germany. He is an executive committee member ATNRCG 20224 to 2026 and IFS Tamil Nadu from 2024 to 2026. uh and currently up to 2028 youth icon in fertility award is 2023 bopal and five chapters authored medical reference text authored by medical reference textbooks he's director of promise fertility center in Chennai and consultant at Shri Kumar and hospital west tambaram his special interests are infertility reproductive medicine and high-risisk and male infertility over to you ma'am and sir >> so thank you >> yeah we have been looking forward to this debate I'm sure it's going to be uh real fight between Priya and Anut.

[00:43:53]>> Yes, madam. Even if it is unrealistic, we fight till the end.

[00:43:57]>> Okay, let's get on with it.

[00:43:59]>> Time I have got a very good realistic fighter. I'm very happy to fight over with Dr. Anit Kumar. So, so PCOS to PMOS the name change the disorder needs today. My answer is no. I like the old name. I like it to be called it PCOS. I still like to remain as PCOS. So with that note, I will start off with that. Not everything needs to be perfect to be wonderful.

[00:44:30]So that is the note with which my whole scenario is going to stay. PCOS is one of the world's most recognized endocrine disorder. While imperfect, the term has become deeply embedded in clinical practice, research, guidelines, insurance coding and patient education.

[00:44:49]Changing the name to POS risk the creating more confusion rather than clarity without improving patient outcome.

[00:45:00]Historic fact, it is not a new name. It was first given in 1935 by American gynecologist. We know that it is teen and levental who gave it and we even initially referred it to as teen lental syndrome. So it is over a 90 year legacy. So it's not just a name just came two days back and then you can just take it off. So it is a 90-year legacy which we cannot give. And not all women have problem with this name. Some women even put it like that. I am so classy that even my ovaries try to wear a string of pearls. So this is a meme which I picked but many of the women are okay to say we are peacocks. So it's not that everybody had a problem. First of all why did they consider the global need for this change. They found like you know we know that one in eight women worldwide which accounts for about 170 million women worldwide they are affected with this condition the polycystic ovaries and out of which only 22,000 responses have been collected and from 56 patient organizations and the performances by multiple workshops they collected the details and they were they were few were health care professionals many of them were women living with the PCOS is and women with the condition were the biggest drivers for the name change. So it is not a name change which is given by the doctors. It is actually a name change is suggested by the patients. So they argue that the name focuses too much on the ovaries where they might think that PCOS is only a gynecological issue. The main reason they considered is to better represent the full range of health issues that happens with the PCOS. Like this only we argued and we handed over a breast organ to the surgeons. Initially breast was dealt by gynecologist. No more gynecologists are dealing with breast.

[00:46:56]We don't know anything about breast.

[00:46:58]It's become a disease of the surgeon.

[00:47:00]And now sooner we are handing over our ovaries to the endocrinologist by calling it as poly metabolic ovarian syndrome. Though there is the part of ovary sticking somewhere it is metabolic syndrome. So the moment the patient hears it she will ask charg what metabolic means? It is something to do with endocrine polyendocrine then they will land up with the endocrinologist.

[00:47:24]So you have no role there at all. You are handing over your ovaries to the endocrinologist. So you have to think very carefully whether you really need to hand it over to them.

[00:47:33]The problem here is biology not the terminology. PCOS is a heterogeneous symptom. Yes. Like however we have many diseases which has inaccurate historical names. Diabetes means sweet urine. Do we go and taste the urine? No. We don't know whether it's sweet or not. Though we have to name it as sugar in the urine, the diabetes is still meaning sweet urine only. Heart failure is a misnomer. If the heart has failed means the patient is dead. The heart is not yet failed. It is reduced work and lupus meaning wolf. So medicine evolves despite imperfect normal nature. Just changing the nerve will not improve the diagnosis or the treatment. PCOS is already a global brand. You cannot change the brand name. Okay. Like how our Vijay comes and says Talpati has told you I want to break the brand name.

[00:48:24]I don't like the brand name to be broken. It is having a 30 years of research, 20,000 publication, international guidelines, WH ICD codings, patient advocacy groups.

[00:48:36]Changing the terminology may fragment these literature and reduce the continuity of the full known disease which has been researched for more than 30 years. Polycystic ovaries are not needed for the diagnosis. We completely agree with it and already the clinician know these things. So it is like you know not a new thing. this name change is going to tell them. We all know PCOS is not needed only. So it is not that we are going to think what the patient understands doesn't matter until the clinician understands what the disease is. So we know the modern criteria chooses hyperandroenism, ovarian dysfunction along with metabolic dysfunction. We all know these things.

[00:49:16]Ultrasound is one optional. Educating the patient is more important. It is not renaming which is going to be the solution for this problem. PMOS may oversimplify the disease. It focuses more on metabolism. But however, PCOS it concentrates on the neuro uh I mean hyperandroenism, neuroendocrine dysfunction, reproductive genetic predisposion. We have this inflammatory pathway which is sitting on there. We know that gut dispiosis is the reason more of stress coming that sleep is the pattern there. So these are never been addressed by these PMOS terms and not every patient is metabolically unhealthy. There are lot of women who are metabolically normal. So what will we call them? They are not PMOS at all because they are not metabolically unstable and they don't even have a other uh endocrine disability as well.

[00:50:07]They only have irregular cycles which doesn't qualify them as any of them. And however incidence of metabolic syndrome overall ranges wly between 35 to 45%. So less than 50% only is metabolic syndrome. The remaining 50% of the women are metabolically normal. So why to go and push every women saying that you're going to become diabetic, hypertensive, you're going to have lipids and then you're going to have heart attack. So this is going to be causing more of a panic rather than telling them you have some cyst in the ovary. So you know like we have to reconsider these things. Lean PCOS still exist. Almost 30% of these patient are still lean. And we all know that metabolic syndrome though it appears in the lean PCS it's not to that level as compared to an obese PCOS. It just stigmatizes these lean women falsely imply that obesity is the main reason and then they delay the diagnosis of PCOS in this set of women will be just forget it and it is a huge implementation cost. So changing the terminology you may affect the guidelines medical textbook. So you have to reprint rewrite redo it everything.

[00:51:12]So change the coding. It is going to cost millions and millions of money.

[00:51:16]Going and making your insurance company understand that PMOS is same as PCOS is going to take you know a decade or more maybe more than that. Maybe patients will have insurance claim rejections just by the name change because we don't understand electronic record research database. So everything is going to be there. So both financial and the logistic burden are going to be enormous and no evidence to say that the renaming improves the outcome. No study has shown that it diagnoses early. It has better fertility outcome. It improves the metabolic screening. Reduces the cardiovascular risk. So we don't have any study to share that it is just it is like you know peach patients are happy that I don't have system that is the only happiness we are giving them. So the outcome improvement depends upon the care just not the change in the terminology and again we know that changing in the healthy lifestyle habit is not about going with the longevity medicine or something else which is come new. It is about coming back to your lifestyle focusing on healthy diet and exercise. Nowadays nobody wants apple to keep the doctor away. They want to have a medicine or injections to keep us awake. So this changing the label without changing the care is just like cosmetic medicine just like going to a parlor just putting some makeup coming out of that it is not your actual care of treatment and does this change going to guarantee that this new name is going to be used. So these are the other diseases where the new names have been given non-alcoholic fatty liver they again gave it as metabolic dysfunctional disorder associated steotic liver disease nobody uses that we still uses NLD only mental retardation which was toined as intellectual disability even now only I came to know but we are not using that because we wanted to give a respectful terminology but what doctors understand is only this and still we call it as ITP we don't call it as immune immune thrombocytoenia we call it still as idiopathic thrombocytoenic perpurum so how do we write the prescription how I write I will tell you I'll be honest I will not be like an will come and like you know tell all stories I still write it like PCOS bar POS so one thing is I know POS is a new term I hope all the doctor who sees the prescription next will also be seeing at this yes this is POS not to think that what is this mad woman written some disease She doesn't even know PCOS and she's written scribbled something. So it should not be there till everybody who's practicing medicine understands that PMO is the term. There is no point in going and arguing. It's a good term there. And um so to conclude PCOS name change I will say no. PCOS itself is a good one. Name change does not immediately replace the old term in clinical practice and successful adoption depends on whether the new term is more clinically uh scientifically accurate, clinically useful and endorsed by the professional societies. So thank you. Thank you for the wonderful opportunity.

[00:54:25]Oh, ma'am ma'am, you're muted.

[00:54:27]>> Ma'am, ma'am, you're muted, ma'am.

[00:54:31]>> Yeah. Yeah. I was just saying you made a you made a very strong case for the terminology PCOS. Uh we have it's a legacy given to us. We know stain lethal syndrome. We know PCOS for years.

[00:54:43]Initially, it was only the medical students know who knew it. Now, everyone, every adolescent also knows it's there is something called PCOS. So changing the name uh they start getting confused and then already the awareness exists and like you rightly said the metabolic uh factors not everyone with PCOS has it right there is a lean PCOS which may not have it and ovarian dysfunction is central to this condition whatever other metabolic problems may exist ovarian dysfunction is central to the problem okay now let's see what doctor I had logistics as well you have to spend a lot of money in changing the name in all the records, the databases, the research articles, all our textbooks. Just imagine the huge amount of money >> over it to my endocrinologist. Madam >> exactly handling handing over. So let's say now what Dr. Anit has to say for PMOS and against our well-loved name PCOS. Dr. Anit, the quote is yours.

[00:55:43]>> Uh thank you madam. Uh thank you Priya madam for setting the stage. Um so we have a very uh we did listen to a very strong debate saying that we should continue the name PMOS. Uh but my proposition is that PMOS is definitely necessary and uh it has been wrongly named for the past 90 years and uh it is corrected today. So renaming PCOS is not just cosmetic. uh it was an overdue correction and it is a 90-y old mistake that we have uh the internationally steps have been taken uh to get it right. Uh so the problem is a wrong word can create a wrong picture and patients are wronged at the wrong time actually.

[00:56:26]Uh so the so there was the three reasons that the name has to go and um it was changed. So um for um so the term policy stick was actually pretty confusing and it was a wrong name and people in 1935 did not have this much of understanding what we have in 2026 uh definitely have we have almost 90 years of research and understanding and we have uh made sure that uh we this a much needed uh thing right now and uh because it is named as policy mistake um it misleads every doctor who reads it and it also confuses every woman who receives that uh term that she is PCOS.

[00:57:07]So basically uh why uh that it's confusion is we have to agree that all gynecologists agree that there are no cyst in PCOS and there were never any cyst in a PCOS woman. So because that cyst is always confusing it a lot of um stress on the woman. So what these systems are basically these small that PCOD name was there these are small arrested antrical follicles that is these are follicles that have been developed in their mid are arrested. So this entire disease is named after mirage that never existed in the first place. Uh so the other even the other sid did say in one of the slides that that the name could be false. So what are they still defending? I still don't know. So there is actually an increase in so the question false is is there actually no increase in abnormal cyst in the ovaries. Yes that is true. This is often misleads us and uh one important fact to be shown that that healthy young women so when they are teenagers in 18 to 22 there was one study that say that almost 83%age of women uh can have polycystic looking appearance. So we have also continuously patients who who have come to us uh with reports saying that they have a PCOS but they are absolutely normal. They'll have regular cycles. They are lean looking. They have no problem but just because they have an ultrasound scan report showing that PCOS patient just takes the scan report and shouts in her face that say that she has PCOS and we have nothing to treat.

[00:58:40]Basically we just have to sit and console them. So meanwhile women who truly have it but show no cyst are told totally fine. So sometimes the woman may not have a proper PCO looking ovary but she will be very hyper androgenic.

[00:58:54]She'll have obesity she'll have anovvelation and a PCO and but still she'll not be late PCOS because the ultrasound does not show that she has a PCOS. So it is always misleading us and it is always confusing us and if uh if there was PCOS as a single name disorder for all the disease we have multiple subtypes of PCOS which has still not been able to classify under one group of disease and still it needs lot of subclassification.

[00:59:22]So now we have a truth. So it is now known as polyendocrine metabolic syndrome. So polyendocrine basically means there are many hormone systems are colliding at once. It is metabolic because it has a problem with insulin resistance which is the central of the problem. It has impaired glucose. There is increased weight and there is a problem with the heart. And as Priyak Priyakan madam was saying that we gynecologist will not lose importance because the P O has O in it. So the ovary is not left out. So even in the even in this four words the ovary has been given importance and ovary is what make makes pure noise an important part because gynecologist is where the patient comes lands in first. So any problem with the patient sees any if her whole metabolic system first reflects a problem of her periods. So first she gets anolary cycles. So she doesn't go to an endocrinologist. She doesn't go to a diabetist. She doesn't go to a physician. She comes to a gynecologist first and luckily girl women have this problem of ano cycle which shows that they could have a metabolic syndrome at early. So intervening early giving them proper lifestyle changes giving them proper uh diet pattern controlling their weight controlling the metabolic systems puts the woman in the right path for long-term metabolic correction which could never have been priorly said if you just label a PCOS and concentrate only on ovaries. So in putting importance the whole part becomes a lot of importance.

[01:00:59]So so I hope that we understand that it is never about the cyst and the central part of the whole PCOS or the PMOS is basically insulin resistance. So almost 75 to 95%age of patients are insulin resistance. She doesn't matter whether she's lean or overweight. Even in a lean PCOS she has insulin resistance because she lacks muscle mass. And in overweight PCOS she has insulin resistance because she has excessive of a postu. So ovary is auh is where we see it. So so ovary is where it it is shown very clearly. It has been able to pick up very early by gynecologist and because of the metabolic change or is picked up early and she could have a lifeline of changes if she's addressed.

[01:01:47]So what was ex exactly harming the woman? So a woman with PCOS previously now PMOS has a type two diabetes risk almost four times higher than what she can ever have. She has an heart disease increased risk of a 1.2 and she does have increased risk of fatty liver apnea there is an increased score of endome endometal cancer. If it was only polycystic ovaries, all these other systems will never be thought for and just because we have metabolic name in it, it changes how we look at the condition and then it puts more perspective into it. So remember who this is for. This is not for us doctor.

[01:02:24]This is for the patient to see who had waited for so long to get her disease diagnosed. So every year is lost just because a misleading label is on her life. The debate is not about what it looks about. It is about the woman's what exact treatment she needs. So there are lot of lives her years are lost just because saying it is PCOS and never concentrating on the metabolic part.

[01:02:47]There is enough data to show that one in three women wait over two years to be diagnosed if she is having any metabolic woman. Nearly half of these three are uh are more see more than three doctors and 70%age worldwide are never diagnosed that she has a metabolic condition.

[01:03:05]So and this change was a very interesting change. So this uh this change was in worldwide change. So it included a lot of parameters. It included doctors and more importantly it included patients patients who are living with PCOS and almost 86% of the person of the patient did want name change because they felt they were less addressed because the their name was new and it was more based on the symptoms that she's actually feeling the condition that she's actually suffering.

[01:03:36]So majority rejected the old out acronym outright. So m majority women say that PCOS is not correct and the doctors are not renaming the disease. is actually the patients are reclaiming what the condition is actually is and madam said this is not a rebrand it is actually a correction for what it has long due. So no name in the medicine has been tested hard. So this is one of the most and uh well researched name change. This this has made a precedent uh of how a name change should actually occur and um this was uh this the name change is actually a important milestone and important study protocol of how future name changes should actually be there. So this involved almost 22,000 stakeholders. It was done over a period of 11 years. Almost 56 organizations were involved and there's lot of multiple deli and nominal groups have changed. The call was not hasty and it was a very systematic change was occurs.

[01:04:33]So among the people who were voted almost 88 of the 90 people voted that they need a name change for PCOS and only two people did not say like Priyakan that the name is is not as old.

[01:04:44]So this is a very landmark uh name that has been resisted. Uh so every so we previously change like heart attack because model of people resisted but this was made correct. So we have previous name change as madam was said.

[01:04:58]So factory liver is now renamed to MSD.

[01:05:01]Vness granomatus is now called as granomatus with polyangitis. Manic depression disorders is now called bipolar disorders and mental retardation is no more called mental retardation is because it affects the patient. It is called intellectual disability. History does not remember the objectives. It is more about what the patient actually feels. The question is no longer whether the whole name is wrong. It is how long we keep defending it. So it is not in western import. It is our own epidemic.

[01:05:26]So 90%age of 90 million Indian women adults are suffering with diabetes and India is the second largest burden and metabolic is a word that the patients have never heard and it has been the word that has been waiting for a long time. So Indian patients needs to be addressed that they need to have a metabolic shift as early as possible. So in India it te falls even more important because we Indians are more prone to develop diabetes and metabolic syndrome at a very early age. So so the thin so in India we have a thin fat phenomena.

[01:05:55]So we do develop a lot of visceral fat and insulin resistance is much more high even on a normal Bway that is why we have a low BMA cutff. So the metabolic name catches the risk which is cyst could never do in the past. So it is a metabolic condition and nowhere in the world name was that mentioned and this change is absolutely justified. So PCOS society I hope the change named PMO society soon. So PC society of India vice president Dr. Madra Patel did say that it and uh it is an very good change name. So the truth needs no apology. So before single every single outcome improves patient the diagnosis tells the truth and carries less stigma. So the patient has less stigma now she doesn't have to worry about stigma. The accuracy is not cosmetic. It is the foundation of the trust of medicine. So one name describes a shadow. The other describes the disease. The PS is a picture that was never real and POS the patient has the truth at last and she can take proper changes. So I was able to attend Sray. So I had luckily taken a photo of that estray meeting. So there is a lot of changes that has been underway for it. So that is that um the NSA they published that they have around eight uh changes how they want to include a name change. So they are going to do public dissemination through lancet and all the articles there's going to be patient communication article throughout this.

[01:07:15]So social media there's a lot of talked about so the Instagram post by the PCOS for this change almost had 75 social median media and all the comments were very supportive the name change even the general public were very happy about the name change. So there was a health information system uh government agencies have been probed into it and in PubMed and research term that includes mesh terms. So almost um all the mesh terms are being steps are taken to change the mesh terms for pub searches. So the PMOS is more included. So almost now top 100 journals and editors letters were there for the name change. So even the wh included ICD name change has already been done.

[01:07:56]Reclassification has been done. So no need to worry about all the millions of money that are going missing and it's a global education front that is going being forward. Textbook changes are then happening and even Harrison's has accepted change the name in the upcoming edition. So it's already underway there's no problem in that and international guidelines are coming up and the good news is NICE guideline has already changed the name to POS. So already guideline change has occurred and there is a standalone uh 2028 PMOS guideline is going to come out in 2028.

[01:08:28]So everything is underway. So it's a lot of changes are going to happen and initially there was a this patient who was a patient supported almost as I said it. So there was a patient who came and talked about that she is feeling very good because for 10 years to 15 years she was never diagnosed to have a metabolic problem because she was a lean PCOS and because of the name change uh the general physician was able to think in large. So this is not just about gynecologist. It is about making the general physicians and the general practitioners think in terms of how the name could affect the woman and make them think that okay this is just not a ovarian problem. It could be metabolic problem and we as general physicians also need to play a important role. So uh so definitely let us hope the judge votes in favor of the name change. PM is not just a better name. It is an honest one. So I hope the house uh supports that change in name.

[01:09:22]>> Thank you Dr. Anit. You have made a very strong case for the change in name to POS. Dr. Priya any rebuttals?

[01:09:31]>> Definitely I do have ma'am.

[01:09:37]If it didn't, I would be surprised.

[01:09:38]>> Yes. Thank you for Dr. Anit. He agreed this name change. Yes, we agree. It was like 22,000 entries were taken and 86% of them were patients. Okay. So, this name change was suggested by patients and he also mentioned >> no no 86% of patients accepted the name change in the patient cohort. Okay, that's what and actually most of the women the name change mainly came from patient co pat again and then and and then you said like no among the doctors voted so societies and the 90 88 pat people voted in favor for so it is >> no no the doctors so at the end of the day I had 90 people voted the the doctors and the stakeholders out of 90 stakeholders 88 voted for the name change only two didn't the two doctors didn't know but >> the only thing which we want to say is that okay uh it we all know we all know PCOS is about metabolic syndrome so it is no news to the doctor maybe it is a news to the patient and even otherwise a patient herself going and evaluating for metabolic syndrome it can be delirious for the society I have patients who think they are metabolically abnormal who think they are obese they go on drastic diet I have a 45 kg anorexic patient I'm not able to make her eat because she was little bit plumpier before and I think something has gone into her and I saw her as a obese patient now she's going down by down because she's more scared about getting metabolic syndrome heart attack which is happening in the family and we are evaluating for tuberculosis all other reasons for weight loss and basically it is anorexia finally we are like you know shifting her over to the psychiatrist to give a eating habit so like you know we are just pushing this PCOS into a more metabolically scary thing where people are going to go on drastic diet and then they are going to do that. So it is not for the patients to understand. It is always for the physicians who already know PCOS is a metabolic disorder. So the name change need not be a part of that to involve the anorexic women and already we know that we are thin fat women. we should concentrate more on uh protein intake and healthy intake not about drastically not eating anything and suffering to prevent this metabolic disorder. So that is why I will stick on to old name as of now okay >> he's dumb struck now by your arguments.

[01:12:17]No, no, no. So um uh so much. So what what madam is talking is about the extremes of patients. So for us many of the patients who do not exercise and they do not understand the metabolic impact they going to have, they don't understand that in a few years they might be diabetic. So how many GDM patients you have actually dieted and I have not prevented diabetes from happening. So what the extents of patient is what that is going to be majority of the patient I think will do benefit they if they understand that they have a risk of diabetes in the future they have a risk of long-term metabolic problems in the future and I hope that they do work uh in in their lifestyle to change all those from prevent those from happening so preventing diabetes and preventing obesity if they understand early stage they they could have could have even an e economic benefit for the whole country as a will not talk also because they will directly go to endocrinologist. No gynecologist at all.

[01:13:23]>> Okay. Over to you.

[01:13:24]>> So uh Dr. Priya and Dr. Anit both worthy opponents. We have heard both sides of the story. Now this is just not about the four letters that we see. It says PC OS P M OS. So whe we have to understand whether this patient name change also was that the PM one point they mentioned name was actually chosen by marketing experts also there are a lot of so that because PO and PCOS because there's only one change it'll be better accepted by everyone so even they consulted marketing experts regarding the name change also >> that is why I don't like should not be involved in these things right No, it is made. So it is to easy acceptability how >> acceptability >> you will see along the way what happens with us both worthy opponents both have stated your cases like it's basically whether this patient is she feels seen understood whether she's diagnosed correctly or and treated correctly as well. So for PCOS what we would say is there's a huge awareness now almost everybody every woman and the daughters they all know what PCO is. So immediately the girl has irregular cycles. A mother brings her assuming it's PCOS and worried about her future pregnancy um future fertility issues. So not everyone has metabolic issues though they are present but it's up to us to diagnose that and as such ovarian dysfunction is the key. So probably then we shouldn't rename the disease but reform the care. So that is what I would say for PCOS. Now whereas for PMOS like you said ultrasound doesn't necessarily show the typical features in all cases we are seeing that daytoday they have all the clinical uh appearance and all the issues of polycystic ovaries clinical criteria are present but the ultrasound doesn't confirm PCOS by the typical look of the ovaries. PMOS most more accurate as a medically medical term. PMOS describes a condition accurately. It covers the heart and diabetes and liver risks in details. Also main thing it reduces the fear of cysts and cancer.

[01:15:39]Now when a girl comes to us or young woman comes to us and we say you have polycystic ovaries the first understanding is that they have cysts near children they think it is cysts which require surgery or possibility of cancer. So now if you rename it that fear is removed from their minds you know and it encourages also the multiddisciplinary uh treatment in these cases we will now involve the endocrinologists and uh we'll involve the physicians and we push for whole body care okay and this term also removes the stigma that's why I think many of the women who wanted PMO renamed to PMOS basically they're stigmatized by the term PCOS everyone says oh you got PCOS you got PCOD you got PCOS there's a stigma attached to the name she will have problems with fertility she will be obese these are the things she will continue to remain obese she will look all hairy her suit these are the things we uh attribute to PCOS so they are stigmatized possibly this term PMOS will remove that stigma you know and they are going to feel more comfortable with this renaming so maybe then we should take some middle path now as OB gynecologists we have known for some years over the years that there are metabolic consequences of PCOS and we have been looking into that for every woman who walks into the clinic. We have also been testing them for the metabolic problems.

[01:17:02]So the name PCOS doesn't necessarily mean that we are not uh actually looking for metabolic problems, we are actually diagnosing them and correcting them as well. Not only looking at irregular menes and fertility issues. So we have as of gynecologists without the names having been changed we have already started over some years now almost a decade we have understood the metabolic consequences of PCOS and I'm sure all of us are diagnosing and treating them screening them so we have been doing that the main reason for the name change as I said is positively it's a stigma attached to the name now if you have to compromise between the two like probably we should keep the name PCOS but use the term metabolic and in descriptions and as guidelines says and for public awareness we can still use the term PCOS because everybody understands it in research probably we can use POS maybe I don't know so we should tell people that PCOS is more than ovarian cyst and it involves so many different organ systems in the body which needs to be screened and treated instead of renaming.

[01:18:13]Yeah. Yes, she >> PCOS seems comfortable for both the patients and the gynecologists as well.

[01:18:20]>> Tell me the truth, Dr. An. What would you like?

[01:18:23]>> What do you write in the >> Yeah, we'll write in the >> because we have to go with the flow. We have to go with the flow. They have renamed >> POS POS/PCOS >> POS but uh explain to the patient about PCOS and metabolic problems. Yeah.

[01:18:44]>> Yes ma'am. Thank you. Thank you. That was such a >> I think we should end the debate here.

[01:18:47]All of us are comfortable with the renaming. But we should also make sure the patient understands basically polycystic >> oarian disease. Can madam?

[01:18:58]>> Yes madam. Your view on that.

[01:19:03]Ma'am.

[01:19:05]>> Hello ma'am. Can you hear me? Yes ma'am.

[01:19:07]Yes ma'am. Yes ma'am. Thank you.

[01:19:09]>> For patients who have only polycystic ovaries call them PCOS that is without metabolics. If they have metabolics, call them as PO PM. So we need both the names.

[01:19:20]>> You have made it so simple madam.

[01:19:22]>> Super madam.

[01:19:24]>> That's nice.

[01:19:24]>> Yes. Metabolic syndrome let them be continue to be called as PCIs.

[01:19:29]>> They have metabolic syndrome let them be called as PM.

[01:19:33]I'm sure we'll continue to have beating >> continue to be debating on >> for some years to come till we get comfortable. We >> agree. We'll be debating madam.

[01:19:44]>> Okay. Thanks for a wonderful discussion here.

[01:19:47]>> Thank you madam. Thank you ma'am. Deep ma'am. You're there.

[01:19:49]>> Both are winners. Thank you madam.

[01:19:52]>> Thank you ma'am. I know we I mean we have to accept the change. Maybe like till >> Yeah we do.

[01:19:58]>> There we are forced to accept we will say we will be staying with the old name only.

[01:20:02]until they say no no no name is completely changed then we will change after few years have any comments no comments >> no >> no comments and very good uh debaters and the judgment is art okay I like the judgment thank you ma'am >> thanks everyone wonderful discussion both the journal and the debate thank you >> have a quiz so kindly don't leave us so I will hand over the session to Angel.

[01:20:34]>> Thank you Priya ma'am and Anita for that interesting debate and thank you um ma'am for that beautiful judging and Dana ma'am's last punch line was the highlight and uh now moving on to the much awaited quiz session. This will be conducted by Dr. Shahin Jaganatan. She's assistant professor in AC's medical college Chennai. uh completed her MBBS from Tini Medical College and MSOG from PSG IM SR Kimatur DNB OG from New Delhi and fellowship in minimal access surgery from Chennai and uh she's Foxy ICOG critical care obstetric certified and she's also me a member of Oxy Foxy CMS IMS and FPA and over to you ma'am >> thank you for the kind introduction I thank Oxy team Dhana ma'am Priya mam and Deepa mam for giving me this opportunity.

[01:21:24]Uh let's move on to the quiz. Saiti.

[01:21:29]>> Uh yes ma'am. So there will be 30 questions. Yes ma'am. Please.

[01:21:34]>> Yeah. No no no. Yeah you can proceed.

[01:21:35]You can proceed with the general rules.

[01:21:37]>> Yes ma'am. So there will be 30 questions. So each question will be read by Dr. Sharya ma'am. And after ma'am read those uh lines we will be giving only 5 to 10 seconds time for you to answer. So I request all the participants to immediately uh opt the answer and submit it.

[01:21:55]>> Uh you need not download any separate app. The question will pop up to you right on the screen and you can select it.

[01:22:03]>> Yes ma'am. I'm launching the first question >> and do not do anything in the chat box.

[01:22:08]Just in the popup screen you write you put up an answer.

[01:22:13]Correct. Uh yes ma'am. Yes ma'am. You can only select the answer need not write in the chat box. Okay.

[01:22:23]Yes ma'am. I have disabled the chat also so there won't be any confusion.

[01:22:28]>> Wonderful.

[01:22:30]>> You can launch it. Yeah. So the first question, hormonal status in PCOS.

[01:22:35]Option A, LH increased, FSH increased, testosterone increased. Option B, LH decreased, FSH increased, testosterone increased. Option C, LH increased, FSH normal to low, testosterone increased.

[01:22:46]And option D, LH increased, defic normal to low and testosterone decreased.

[01:22:53]>> Seconds timer.

[01:23:00]>> Second question.

[01:23:01]>> Going on to the second.

[01:23:04]What is the evidence for genetic basis of PCOS? A. Familial clustering of cases. B. Concordance greater in identical than nonidentical twin pairs.

[01:23:13]C. mode of inheritance is uncertain.

[01:23:15]It's a complex endocrine disorder likely to be oligogenic or polygenic. D. All of the above.

[01:23:22]>> Five more seconds.

[01:23:28]>> Time out.

[01:23:30]>> So certain questions will be very easy and uh certain questions will be tough.

[01:23:35]So third question, why was LHFSH ratio excluded from NIH 2012 criteria? Option A. Many women with functional hypothalamic aminoria have increased LHFSH ratio. Option B high intercycle variability. Option C is no specific assay were available. And option D normal LH or FSH ratio in lean PCOS.

[01:24:00]>> Five more seconds.

[01:24:00]>> Why was this ratio excluded?

[01:24:05]Time up.

[01:24:12]>> Next question.

[01:24:14]>> Yes, ma'am.

[01:24:16]Just a second.

[01:24:22]Yeah. Fourth question.

[01:24:25]>> What is the LH pulse frequency in PCOS?

[01:24:29]Is it A1 pulse per hour, B 10 pulses per hour, C3 pulses per hour, and D 50 pulses per hour? What is the LH pulse frequency?

[01:24:39]Five more seconds timer.

[01:24:49]Fifth question.

[01:24:52]What percentage of PCOS patients exhibit impact glucose tolerance? A 75 to 85%, B 30 to 40%, C 20 to 25%, and D 7 to 10%.

[01:25:06]>> Five more seconds.

[01:25:10]Timer.

[01:25:14]Sixth question.

[01:25:17]When is an ultrasound diagnosis for PCO morphology advice for adolescence? Is it A 2 years after puberty, B 4 years after puberty, C 8 years after puberty? And D as soon as the clinical diagnosis is suspected.

[01:25:34]>> Five more seconds.

[01:25:38]>> Five more.

[01:25:42]>> Seventh question.

[01:25:45]Which of the following medications does not cause herotism? A. Danol. B.

[01:25:51]Resuppine. C. Methylopa and D none of the above which does not cause hersotism.

[01:25:59]Five more seconds timer.

[01:26:09]Eighth question.

[01:26:12]Effects of high serum androgen levels on endometrium in PCOS results in suppression of alpha v beta3 integrine in the endometrium. Decreased production of glycodelin. Option C is none of the above. Option D is both A and B.

[01:26:30]>> Five more seconds.

[01:26:35]Time up.

[01:26:41]Ninth question.

[01:26:44]>> Very high AMH levels may cause poor response in PCOS due to option A decreased sensitivity to FSH, option B inhibitory effect on aromatase enzyme, option C none of the above and option D both A and B.

[01:27:01]Five more seconds.

[01:27:07]Time out.

[01:27:09]10th question.

[01:27:13]>> Choose the correct statement. Aanthtosis nigricans is seen with genetic syndromes. Aanthtosis nigricans is associated with GI malignancies. C topical retinoids can be used to treat athosis nigricans. And D all of the above.

[01:27:31]Five more seconds.

[01:27:36]Timer up.

[01:27:39]11th question.

[01:27:42]>> Modified fairy man galway scoring for hisutism recommended for far east Asians that is the cutoff. A is it more than three B more than or equal to 8 C it's more than or equal to 9 and D is more than or equal to 11 for far east Asians.

[01:28:01]Five more seconds.

[01:28:07]Time out.

[01:28:11]>> 13th question.

[01:28:14]>> PCOS patients are more prone to develop obstructive sleep apnnea. True or false?

[01:28:19]A is true. B is false.

[01:28:26]5 more seconds.

[01:28:31]Time.

[01:28:34]14th question.

[01:28:37]The cumulative pregnancy rate of women with clomophen citrate in PCOS after 6 months therapy is A 20 to 30% B 40 to 50% C 25 to 35% and D less than 10%.

[01:28:55]Five more seconds timer.

[01:29:03]15th question.

[01:29:07]Which is the criteria for critical?

[01:29:09]Which among these is the criteria for critical OSS? HemTorrit more than 55% WBC count more than 15,000 cells. A C is hypocalemia and D is all of the above.

[01:29:21]Which one fits into the criteria for critical oss?

[01:29:26]>> 5 more seconds.

[01:29:31]Time up.

[01:29:35]16th question.

[01:29:39]High risk for OHSs includes Aesthenic habitus, B more than 10 follicles in IVF, C serum estradiol more than 4 4,000 pig per ml in ovelation induction and D is none of the above.

[01:29:54]Which is the high risk?

[01:29:57]5 more seconds.

[01:30:03]Time out.

[01:30:06]>> 17th question.

[01:30:09]>> Which among these state is the correct statement? Usites from PCOS women develop premature granolosa cell luteinization. B. Usites from PCOS women have increased developmental competence.

[01:30:21]C. Intrafolicular testosterone levels are increased in PCOS patients. And D is all of the above. Which is the correct statement?

[01:30:32]Five more seconds.

[01:30:40]Time out.

[01:30:44]18th question.

[01:30:48]Criteria for diagnosis of metabolic syndrome in adolescence by NCA ATP3 includes triglycerides more than 150, HDL cholesterol less than 50 mg per deciliter, C fasting blood glucose more than 100 mg per deciliter and D all of the above.

[01:31:09]5 more seconds.

[01:31:14]Time out.

[01:31:19]19th question.

[01:31:23]Which microRNA is downregulated in adolescent PCOS? Is it mi RNA 122, B is 451A, C is 155 and D is 15 A bar 161.

[01:31:37]Which microRNA is downregulated in adolescent PCOS?

[01:31:42]>> Five more seconds.

[01:31:47]timer.

[01:31:51]20th question.

[01:31:55]MET PCOS trial is based on A. Efficacy and safety of metformin in pregnancies complicated by PCOS.

[01:32:03]B comparison of efficacy of metformin and chyroininoettol in PCOS patients. C.

[01:32:09]Efficacy of lower dose of metformin,500 versus 2,250 mg while potentially causing fewer GI side effects and D efficacy of semaglutide versus metformin in PCOS.

[01:32:24]10 more seconds.

[01:32:31]Time out.

[01:32:36]21st question.

[01:32:41]Recommended biochemical test for assessing hyper androgenism in PCOS.

[01:32:46]A total or free testosterone. B. Free androgen index. C. Bioavailable testosterone. D. All of the above. Which is the recommended biochemical test for assessing hyperandrogenism?

[01:32:59]>> Five more seconds.

[01:33:05]Timer 202 question.

[01:33:10]Bediatric surgery in PCOS is recommended when BMI A is more than 30 with no co-orbidities is more than 30 with co-orbidities is more than 35 with no co-orbidities and more than 40 with no co-orbidities. When is beriatric surgery recommended?

[01:33:29]Five more seconds.

[01:33:34]Time out.

[01:33:39]23rd question.

[01:33:43]When to switch to from chromophen citrate to let foration induction in PCOS? A when there is no consumption even after six cycles. B the midcycle endometal thickness is less than 7 mm. C clomophin resistance. and all of the above.

[01:34:02]>> Five more seconds.

[01:34:08]>> Timer 24th question.

[01:34:16]Sra that is soluble receptor for advanced glycation and products levels in PCOS is increased or decreased.

[01:34:27]Five more seconds.

[01:34:34]Timer.

[01:34:38]24th question.

[01:34:42]Role of melatonin in PCOS are all except promotes follicular maturation and ovulation through the production of follicles against oxidative stress.

[01:34:51]Increases body weight, BMI and intraabdominal fat. inhibits G&R receptor expression protective effects on corpus lithium against ROS via its antioxidant effect which is not the role of melatonin.

[01:35:06]10 more seconds.

[01:35:17]Timer >> 26th question.

[01:35:24]High adiponin levels are associated with insulin resistance. Is it true or false?

[01:35:31]High adiponin levels.

[01:35:35]>> Five more seconds.

[01:35:42]Time up.

[01:35:45]27th question.

[01:35:50]According to the Rotterdam criteria, how many of the main features must be present to be diagnosed as PCOS? So, at least one, B is at least two, C is all three and D is none of the above. How many major criteria should be there?

[01:36:06]Five more seconds.

[01:36:12]Time out.

[01:36:16]28th question.

[01:36:19]So this is an easy one. The ultrasound appearance characteristic of PCOS is snowstorm appearance, ring of fire appearance, string of pearls appearance and Venetian blind side which is characteristic of PCOS.

[01:36:35]Five more seconds timer 29th question.

[01:36:48]Which of the following is recommended as the initial phicotherapy for most women with PCOS related hysotism? So which is the initial pharmacothotherapy? A combined OCPS, B spironolactone alone, C metformin and D is corticosteroids.

[01:37:07]Five more seconds timer.

[01:37:15]30th question.

[01:37:20]>> Women with PCOS have significantly increased long-term risk for which of the following malignancies? A ovarian cancer, B cervical cancer, C breast cancer. And D endometrial cancer?

[01:37:34]Five more seconds.

[01:37:39]Time.

[01:37:40]Uh 12th question was missed before. So now we are launching it.

[01:37:47]>> So this is a fun one. Identify the personality who is related to PCOS.

[01:37:54]Who do you think this might be? A is Irving Fer Stain. B is Michael Leo Leanthal. C is David Ferryman. Or D is Ian Galloway. So this is Ferryman Galway or Stain or Leventhal. Who is this person?

[01:38:12]Five more seconds.

[01:38:15]Time out.

[01:38:19]>> Yes, ma'am. All the questions.

[01:38:20]>> We are done with all the questions.

[01:38:22]Ma'am, I think the results will be launched in 5 to 10 minutes. It'll take 5 to 10 minutes. Is it okay if you upload it in the group, ma'am?

[01:38:29]>> Yeah, I think so. How much time it will take? Uh, Saiti?

[01:38:34]>> Uh, 5 to 10 minutes, ma'am?

[01:38:37]>> Okay. I think we can put it in the group. I think because you know like it's >> it's almost so I think we will go with a vote of thanks. So Angeline I think we will wind the position.

[01:38:51]>> Yes ma'am.

[01:38:54]>> So we come to the end of insightful and informative evening. Uh I request uh Dr. Deepa ma'am to give the oat of thanks if she's there.

[01:39:06]Deepa ma'am are you there?

[01:39:10]I think uh ma'am I'll do >> yeah yeah you you you >> okay uh so on behalf of Oxy Research and Quiz Committee I'd like to thank our president uh Dana Lakmi madam and secretary Malar Raj madam and treasurer Sumati preman madam and our um uh debaters Priya ma'am and Danitar and our moderator Dr. ma'am for the beautiful discussion and the quiz the wonderful quiz held by Sharia ma'am as well and uh thank thank each and one of us uh for you for joining the session and hope you have a great night. Thank you.

[01:39:47]>> So thank you. Thank you.

[01:39:48]>> Thank you all. Good night.

[01:39:50]>> Thank you. Thank you all.