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Understanding PCOS When Trying to Conceive

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PCOS is a common condition affecting about 15 percent of reproductive age women. Women with PCOS have a higher risk than normal to develop diabetes, heart disease, and uterine cancer. Furthermore, PCOS women who get pregnant run the risk of developing gestational diabetes, fetal demise, and many other pregnancy related complications. It is therefore recommended that all women with PCOS undergo an evaluation prior and during pregnancy.

What is Polycystic Ovarian Syndrome (PCOS)?
PCOS is a syndrome with symptoms that to date still creates much debate among academicians. For example, the criterion was recently changed to add the appearance of multiple cysts (antral follicles) in the ovary diagnosed by ultrasound. The diagnosis of PCOS, for now, is the exclusion of other conditions with two out of the following three symptoms present:

1. No periods or few periods in a year

2. Increased blood “testosterone” levels or the appearance of excess body hair growth

3. Multiple ovarian cysts (better stated as antral follicles less than 12mm)

Yet, many still argue that some of these patients aren’t true PCOS patients, in particular, those that skip periods and have these ultrasound cyst findings without the testosterone/hair elevation.

What causes PCOS?
There is a hereditary pattern associated with PCOS that has been recognized, predisposing some people to get PCOS more than others. In our overweight population, the increased fatty tissue primarily around the abdomen creates insulin resistance. The body needs to create more insulin then to override this resistance because insulin is needed to utilize the sugar/carbs we eat. No insulin equals no energy. This excess insulin now keeps the ovary from ovulating, stimulates it to produce more testosterone, and diminishes the liver’s production of proteins needed to “clean up” testosterone. If the resistance is severe and prolonged, the body will eventually stop making an adequate amount of insulin; sugar builds up in the blood and gets excreted in the urine (diabetes).

What are typical symptoms of PCOS?
The most common symptom noticed from PCOS is from the excess testosterone floating around the body. This will cause an increase in hair growth (hirsuitism) that will be present in the lower abdomen, a lateral extension of pubic hair, increased lower back hair, mild facial hair and acne. A Ferriman-Gallway criterion can be used to denote the severity of hirsuitism and is sometimes used by doctors to denote the severity of hair growth. Since the ovary is not able to ovulate due to the excess insulin, skipped or missing periods will also be noted. In more severe cases, a skin condition from excess insulin called acanthosis nigricans can develop on the back of the neck, breasts, under arms (axilla), and groin. The skin appears thickened and much darker in those areas than the rest of the body.
How does PCOS affect fertility?
A big cause for infertility in PCOS patients is their inability to ovulate, but even if ovulation is stimulated with Clomid, pregnancy rates are still lower than individuals without PCOS. This means there are other factors contributing to infertility than just not ovulating.

Can we measure insulin to diagnose PCOS?
A good diagnosis of insulin resistance remains elusive without the use of insulin clamps, which are costly, invasive, and time consuming. Currently, the best modality to assess insulin resistance is to check a blood fasting glucose/insulin level, followed by a 75gm glucose load with labs repeated two hours later. There is controversy as to what values would constitute insulin resistance, and only by talking with your doctor to asses the lab values can a determination be made.

What are other consequences from having PCOS?
When one doesn’t have periods because of PCOS, the endometrium (tissue inside the uterus) can convert into cancer. Not only that, one can eventually develop hypertension (high blood pressure), high cholesterol, heart disease, and a multitude of other health problems.

Will having PCOS affect my pregnancy?
The biggest risk one undertakes if conceiving with uncorrected PCOS is the acquisition of Gestational Diabetes, which in most cases would require a change in diet and/or insulin given in a shot form. Gestational diabetes can create an overweight fetus, which may create a difficult/traumatic delivery, breathing problems at birth, and in some cases fetal demise. Risk of gestational hypertension would also be present requiring premature delivery if it’s noted to be severe.

How is PCOS treated?
Weight loss to diminish the amount of extra fatty tissue is always the first and best recommendation that can be given. Indeed, even a 5 percent drop in some cases may be enough to restore one’s menstrual cycles. If weight loss is not an option and one is willing to undertake pregnancy risks, then ovulation induction can be performed. In a landmark study, Legro et al (NEJM 2/2007) reported a live birth rate of Metformin (8 percent), Clomid (22 percent), Clomid+Metformin (27 percent) when either was attempted for six months at most. The study demonstrated that sole Metformin use may not be an adequate treatment for fertility purposes in PCOS patients. This study also showed that miscarriages were higher in people who continued Metformin through their first trimester versus those who did not.
Injectable gonadotropins can also be used to stimulate follicular growth with a higher pregnancy rate than Clomid. Finding the “perfect dose” of gonadotropins however is always a challenge for the RE administering them. Give too little, and no follicles will grow. Give just a little too much, and too many follicles grow.

With IVF, multiple follicles can be created, but at the possible expense of developing Ovarian Hyperstimulation Syndrome (OHSS), creating another challenge for the RE. What is also sometimes noted in PCOS patients is that even though many eggs are extracted, a good proportion of the oocytes (eggs) will wind up being immature and not be perfect for fertilization, creating a diminished pregnancy rate; yet IVF is still superior to any other treatment modality for all patients seeking fertility treatment.

Can PCOS return?
Weight gain will cause PCOS to return. It is important, therefore, to always maintain a healthy diet and exercise.

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