Monday, December 2, 2013

Questions, Answers and Encouragement about PCOS


By: ART Fertility Program: Drs. Honea, Houserman, Long and Allemand


PCOS is a common diagnosis among women, but one that can be filled with misinformation and discouragement.  The ART Fertility Specialists help us understand PCOS, what it means to a fertility diagnosis, and why there are plenty of reasons to be optimistic about successful pregnancy after a PCOS diagnosis.



What is PCOS?

PCOS stands for polycystic ovary syndrome, which is a very common condition.  It involves dysfunctional male hormone production by the ovaries.  All females have male hormones to some extent, but a patient with PCOS usually has a much higher level and it affects her ovulation and ability to conceive.  It occurs in anywhere from five to fifteen percent of women, and is probably the most common single diagnosis seen in our office.


How does one diagnose PCOS in a patient?

Common symptoms of PCOS can include irregular or absent menstrual cycles, acne,   and excessive hair growth on chin, sideburns, lower abdomen and around nipples.  These are symptoms that are easy to see.  Once we look a bit deeper, we’ll see multiple small follicles in the ovary (referred to as antral count). An antral count of 12 or greater in one ovary is consistent with PCOS.  We’ll also run androgen blood levels which are often elevated with PCOS.  If a woman has two out of those three criteria – multiple follicles on the ultrasound, elevated male hormone levels, or irregular cycles – it’s likely we’re dealing with PCOS. 


What causes PCOS in women?

We really don’t know the cause.  There is some family history component, but there isn’t any genetic test to determine how likely a woman is to develop PCOS.  Women with a family history do have a higher chance of developing PCOS, but we have patients with no such history.  There are probably some environmental effects as well.  Some of our patients had no symptoms and conceived their first child without any treatment, then gained a significant amount of weight with their first child and started showing symptoms of PCOS.  Most cases we see are weight-related, and often a weight gain can push women over the edge of that hormonal balance and cause PCOS to show itself. 


What is the next step for a patient after PCOS has been diagnosed?

If it is PCOS, the basic decision is if this patient is trying to achieve pregnancy.  If she is, we help her ovulate and release eggs more effectively than her body has been previously.  If the woman isn’t trying to conceive, we focus on balancing out the hormone levels to help reduce her symptoms.


What treatment options are available for women with PCOS?

We spend time talking about what lifestyle management can do to help with symptoms, especially weight management.  Women with PCOS have a two to five time greater risk for developing diabetes.  Weight gain exacerbates PCOS symptoms.  Even a five to ten percent weight loss can improve PCOS symptoms and improve her response to fertility treatments.  We also encourage exercise, avoidance of excessive alcohol and no tobacco use. 


If the patient has never tried any fertility treatments, we will try fertility pills such as Clomid or Letrazole.  Clomid is the only FDA approved fertility pill for treatment of ovulatory dysfunction.   However, it has many side effects including irritability, formation of ovarian cysts, blurred vision, and adverse effect on cervical mucus and uterine lining.  For this reason we often use Letrazole as our first line fertility pill because it has less side effects and similar, if not better, pregnancy rates.  There is much acceptance of Letrazole use in the infertility literature.  We often combine ovulation enhancing drugs with Glucophage to lower insulin resistance.


If fertility pills are not successful, we usually move to gonadotropin therapy referred to as ovulation induction or super ovulation.   Success rates are as high as 20-25% per cycle, but multiple birth rate results are 20-25% twins, 5% triplets and a 2% chance of quadruplets or greater.  One way to avoid triplets or greater is to move to in-vitro fertilization where we can control how many embryos are transferred into the woman’s uterus.  With in-vitro fertilization, there are now ways to avoid ovarian hyperstimulation where ovaries swell to as much as 10 to 15 centimeters in size, much fluid weight is gained and often there are problems with keeping liquids digested.  Hospitalization is then sometimes needed.  The current thinking is for patients who have severe PCOS to use IVF, trigger ovulation with Lupron, a GnRH agonist, retrieve eggs and then freeze the embryos five days later at the blastocyst stage.  So far no severe hyperstimulation has been reported using this strategy.  Thawing of embryos at the blastocyst stage is now 90% successful and resulting pregnancy rates in frozen embryo cycles are excellent. 


What should women with PCOS remember?

We really want to encourage women with PCOS.  This is a very common diagnosis and it can be frustrating to women because there is considerable misinformation in the public domain about what PCOS is and what it is not.  Women with PCOS should be very encouraged about a future pregnancy.  This is something we see every day in our program and we have had great success in helping women conceive after a PCOS diagnosis.  There are many reasons to be hopeful about pregnancy success after a PCOS diagnosis. 

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