Statistics issued by the U.S. Department of Health and Human Services note that between 1 in 10 and 1 in 20 women of reproductive age suffer from PCOS. In the United States alone, 5 million women are currently affected by this condition.
With PCOS, estrogen and progesterone levels are out of balance, leading to a growth of ovarian cysts with symptoms ranging from an irregular menstrual cycle, infertility, cardiac function, acne, and increased hair growth.
Charles from Dreaming of Baby speaks about PCOS with Dr. Sunny Jun, board certified Reproductive Endocrinology and Infertility Specialist, and Co-founder and Co-Medical Director of CCRM San Francisco.
Charles: Welcome to Dreaming of Baby; today we have with us Dr Sunny Jun, a leading Reproductive Endocrinology and Infertility Specialist to discuss PCOS and the effects it has on fertility. Dr. Jun, would you be so kind as to tell our readers a little about yourself and your experience in the industry?
Dr. Sunny Jun, Reproductive Endocrinology and Infertility Specialist: Thank you, Charles, for the opportunity. I am a board certified REI specialist who sees patients with both endocrine and fertility issues. One of my main interests is PCOS.
What makes me more susceptible to PCOS?
Charles: Excellent, so we are in good hands today. Many of our readers are already diagnosed or aware of the condition. I would therefore like to start by asking you, is there a cause behind PCOS or is it a randomly occurring disorder?
Dr. Sunny Jun, Reproductive Endocrinology and Infertility Specialist: The exact cause of PCOS is still unclear. The etiology can be multifactorial, including genetics.
Charles: Have there been any findings that increase the likelihood of having the condition?
Dr. Sunny Jun, Reproductive Endocrinology and Infertility Specialist: Women with increased BMI, hyperinsulinemia, or family history of PCOS or PCOS symptoms may be at increased risk. However, even women without an increased BMI can be diagnosed with this disorder.
‘Early diagnosis is crucial to lead a healthy life and improve fertility.’
Charles: It is my understanding that the severity of PCOS differs between one person and another; if you would be so kind as to explain to us what is happening in the body so we can get a better understanding of the condition itself before delving into the effects it has on fertility.
Dr. Sunny Jun, Reproductive Endocrinology and Infertility Specialist: Genetically, some women may be more prone to producing higher levels of male hormones or insulin and subsequently causing the symptoms of PCOS to appear. Whereas some women, due to lifestyle or environmental factors, may gain weight and potentially develop insulin resistance which can then stimulate increased production of male hormones to trigger symptoms of PCOS like hirsutism, hair loss or irregular periods.
How does PCOS affect my body?
Charles: Understood. So what does PCOS mean exactly, what is happening inside the body of someone diagnosed with PCOS?
Dr. Sunny Jun, Reproductive Endocrinology and Infertility Specialist: Women with this disorder may present with higher levels of male hormones than normal in their blood, or with signs of it such as increased facial/body hair growth or acne, hyperinsulinemia leading to increased weight gain in the abdominal area, and skin changes such as acanthosis nigricans (dark, velvety texture) or irregular periods. On ultrasound they may also present with numerous “cysts” which are actually resting follicles or fluid-filled sacs that contain the eggs.
Charles: So effectively, the condition has many factors but the predominant result would be the arrested follicles (cysts)?
Dr. Sunny Jun, Reproductive Endocrinology and Infertility Specialist: The predominant result of PCOS can be infrequent ovulation and thus leading to infertility, signs of elevated male hormones or potential consequences from hyperinsulinemia and weight gain.
Charles: I am going to assume that these tests would rule out any other conditions; if this assumption is correct, are there many similar conditions or is the diagnosis fast and straight forward?
Dr. Sunny Jun, Reproductive Endocrinology and Infertility Specialist: If other conditions such as elevated prolactin levels, abnormal thyroid status, adrenal issues and abnormal cortisol levels are ruled out, then diagnosing PCOS is fairly straightforward. REI specialists tend to use the Rotterdam criteria for diagnosis. Women need to meet 2 out of the 3 criteria which include 1. Irregular periods 2. Clinical or laboratory signs of elevated male hormones 3. Numerous follicles in the ovaries.
Lifestyle Choices and PCOS
Charles: So a diet high in carbohydrates and unrefined sugars would have a direct effect on the condition? How much of an impact does diet and lifestyle have on fertility?
Dr. Sunny Jun, Reproductive Endocrinology and Infertility Specialist: Especially if the women are overweight, diet and lifestyle can have a significant impact on fertility. Not only will they have a better chance at conceiving, but once they are pregnant, reducing carbohydrates in PCOS women will reduce the risk of developing gestational diabetes as well.
Charles: Has there been any studies linking a changing “human diet” to increased rates of PCOS or increased severity of PCOS?
Dr. Sunny Jun, Reproductive Endocrinology and Infertility Specialist: As we all know, diet can have a significant impact on weight. Basically, reducing weight in overweight women with PCOS has been demonstrated to increase pregnancy rates. If women with a higher genetic tendency to developing PCOS have a poor diet and subsequently gain weight, this may then trigger PCOS symptoms.
‘Reducing carbohydrates in PCOS women will reduce the risk of developing gestational diabetes as well.’
Charles: So reaching back to the start of our interview, would it be safe to say that whilst the exact etiology of the condition is not clear; there is a clear impact on the condition due to dietary choices?
Dr. Sunny Jun, Reproductive Endocrinology and Infertility Specialist: Yes. We check glucose, insulin and cholesterol levels. Depending on the levels and their BMI, we would recommend modifying their diet and increasing exercise to lose weight. Again, there are women with PCOS who do not fit this picture and are not overweight and have normal blood tests. In these women, it is still important to maintain a healthy lifestyle and weight.
Achieving pregnancy as a PCOS patient
Charles: Focusing on women who are trying to conceive or hoping to conceive in the future, once PCOS is diagnosed what would be the next step in their journey to becoming a parent?
Dr. Sunny Jun, Reproductive Endocrinology and Infertility Specialist: After they are diagnosed, if they are overweight, women are highly encouraged to modify their lifestyle to maintain a healthy diet which includes decreasing carbohydrates to some extent and exercising to lose about 5-10% of their current weight. Numerous studies have shown the benefits of losing weight in women with an elevated BMI and increasing pregnancy rates.
‘Numerous studies have shown the benefits of losing weight in women with an elevated BMI and increasing pregnancy rates.’
Charles: Whilst the condition improves due to dietary changes I am assuming sadly that often this is not enough and other treatments will be required to improve fertility. What comes next in terms of treatment?
Dr. Sunny Jun, Reproductive Endocrinology and Infertility Specialist: Although there still needs to be further studies, in women who may have insulin resistance (higher levels of insulin), a medication called Metformin may help regulate their cycles, potentially decrease a few pounds, reduce signs of hyperandrogenism and improve their hyperinsulinemia. In most women who come and see us, they have difficulty conceiving due to irregular ovulation. Therefore, we have ovulation induction agents such as Clomid and Letrozole to help women ovulate on a more regular basis and make it easier for them to time intercourse. If these oral agents are not successful, we also have hormone injections that directly stimulate the ovaries to grow follicles. Due to the potency of these injections, we need to closely monitor these patients and adjust the dosage to prevent too many eggs from developing and ovulating. They could be at risk for multiple gestation.
Charles: Are there any treatments given to control the hormones causing the condition?
Dr. Sunny Jun, Reproductive Endocrinology and Infertility Specialist: It depends on if the women are planning on conceiving or not. If they are not planning to conceive, birth control pills are effective at regulating their periods and also potentially helping with symptoms of increased acne and hair growth. Birth control pills increase sex hormone binding globulins that help bind the excess testosterone and thus reduce these signs and symptoms. Spironolactone is also a medication that can help with hyperandrogenic symptoms. This is not recommended in women who are trying to conceive. Women who are trying to conceive may benefit from Metformin if indicated by their blood tests. And then as I had mentioned before, the fertility medications.
What happens to arrested follicles due to PCOS?
Charles: We mentioned the arrested follicles which contain the eggs; are these eggs lost forever once they fail to reach their destination?
Dr. Sunny Jun, Reproductive Endocrinology and Infertility Specialist: These resting follicles with oral ovulation induction agents such as Clomid or Letrozole or with hormonal injections can be stimulated to grow and ovulate eggs.
‘Although PCOS patients may have a high quantity of eggs, not all eggs may be of good quality.’
Charles: Wow so, potentially these could at some point be used or retrieved for an IVF cycle, which I understand can at times be the last resort for getting pregnant if PCOS is severe?
Dr. Sunny Jun, Reproductive Endocrinology and Infertility Specialist: Higher doses of hormone injections are utilized in IVF. Therefore, there can potentially be a very high number of eggs. Although PCOS patients may have a high quantity of eggs, not all eggs may be of good quality.
Charles: Evaluating the egg quality would I believe be done by an embryologist inside the lab under a microscope? Or can it be done without extracting the eggs?
Dr. Sunny Jun, Reproductive Endocrinology and Infertility Specialist: Currently, we cannot check the quality of the egg. We can have an idea of the quality by how they look under the microscope, how they fertilize and how they develop into embryos. Once at a certain stage in embryo development, there is a way to then check the “quality” or the genetic component of the embryo by a procedure called CCS or comprehensive chromosomal screening.
Charles: Excellent, we appreciate your insight into the condition, causes and potential treatments. As a closing note, is there anything you feel someone suffering from PCOS needs to know that is not generally discussed or known by sufferers?
Dr. Sunny Jun, Reproductive Endocrinology and Infertility Specialist: A diagnosis of PCOS, especially in women who are trying conceive, can be anxiety provoking. However, PCOS patients tend to be quite successful with the help of fertility treatments. Therefore, early diagnosis is crucial to lead a healthy life and improve fertility. Women should not delay seeking help from their OB/GYN or fertility specialist.