Albeit being a very common health condition amongst women of reproductive age, there is surprisingly a lot of confusion as to what the syndrome really entails. With terms such as cysts, follicles, and eggs being used interchangeably, it’s natural to feel confused if you’ve been recently diagnosed.
Daniela from Dreaming of Baby goes back to the not-so-basic basics in her discussion on PCOS with Dr. Rebecca Chilvers, board certified Obstetrician and Gynecologist, and Reproductive Endocrinology and Infertility Specialist at the Fertility Specialists of Texas. Recognized as one of ‘America’s Top Obstetricians and Gynecologists’, Dr. Chilvers shares insight on what you need to know about PCOS and fertility.
Daniela: Good morning, Dr. Chilvers, and welcome to Dreaming of Baby; so glad that you could join us today. As part of our PCOS segment, we shall be discussing PCOS and infertility, more specifically on what the condition is and managing it with the aim of achieving pregnancy. If you would be so kind as to tell our readers a little about yourself before we dig into the subject.
Dr. Rebecca Chilvers: Good morning, happy to answer questions and thank you for having me. I am an OB/GYN; I did four years of general practice in my training, which encompassed all areas of obstetrics and gynecology. For the past ten years, seven of which have been in private practice, I have been dedicated and focused on helping families overcome infertility. I live in Frisco (northern suburb of Dallas) with my husband and our two children, who have given me perspective as a physician mom.
How does PCOS affect fertility?
Daniela: Thank you for this overview. As a first question, why and how does PCOS affect fertility?
Dr. Rebecca Chilvers: PCOS affects fertility primarily by causing problems with ovulation. It is thought to result from abnormalities in insulin resistance but is what we call “multifactorial” in medicine – there are likely many causes. The result is a collection of symptoms, and some women only experience some of those symptoms. But the problems with ovulation are the main issue.
Daniela Thank you for clarifying that. We would also like to get a better understanding of PCOS’s varying degrees of severity; can you explain a little about the differences?
‘The more eggs a woman has with PCOS, usually the less frequent their periods and the more severe their ovulation issues.’
Dr. Rebecca Chilvers: There are different ways to diagnose PCOS. Most women have an excess in numbers of eggs, which is good from the standpoint of having a lot to work with for making babies with treatment, but this leads to ovulation issues. I find the more eggs a woman has with PCOS, usually the less frequent their periods and the more severe their ovulation issues.
There are 3 main criteria established in our field for the diagnosis of PCOS: 1) irregular cycles, 2) clinical or laboratory evidence of high androgen (testosterone) levels, and 3) polycystic ovaries on ultrasound. Having 2 of the 3 criteria satisfies the diagnosis. The most severe cases of PCOS involve patients having all three and usually they will have family history of diabetes and have symptoms such as weight gain, acne, and hair loss. Sometimes this can also lead to a depressed mood, which is understandable, especially if they are also trying to conceive.
PCOS and Pregnancy
Daniela: In this case then, would treatment differ based on the severity of the condition?
Dr. Rebecca Chilvers: For patients who have mainly elevated testosterone and irregular cycles but who are lean, I would not recommend weight loss, but for those who are overweight I recommend they work on diet and exercise to achieve a safe weight for better pregnancy outcomes for them and for their baby. Also, weight loss will help fertility treatments be more effective and reduce risks of miscarriage and stillbirth. Otherwise, the main treatment for individuals with PCOS is helping them mature 1-3 follicles (sacs of fluid in the ovaries that contain eggs) for ovulation so that they can conceive with timed intercourse or intrauterine insemination (IUI). In vitro fertilization (IVF) is also an option for these individuals and can help reduce risks of multiple births if one embryo is placed back into the uterus per desired pregnancy.
To further explain IUI, all of my patients also have a fertility evaluation to look at their uterus and tubes and also their husband’s sperm, so these factors are considered as well. IUI is the process where washed sperm is suspended in a small amount of fluid that the uterus can hold and is injected into the uterus with a soft catheter that is placed through the cervix. The process of IUI for the patient is somewhat similar to a pap smear. The sperm are given a head start to reach the fallopian tubes, where the egg should be waiting after ovulation to be fertilized. The husband’s sperm count and motility must be adequate to do an IUI, and this is assessed at an early visit with a semen analysis.
Daniela: With reference to your earlier note, are women who suffer from PCOS more at risk of miscarriage and stillbirth?
Dr. Rebecca Chilvers: There is evidence that women with PCOS have a higher risk of first-trimester miscarriage, in studies that have been controlled for age and other factors. Studies have also shown that patients in general who have a higher body mass index, especially over BMI of 40, have a higher risk of stillbirth, and many patients with PCOS struggle with their weight.
‘The severity of PCOS can be gauged in different ways, but the treatments are still chosen based on the patient’s age and ovarian reserve, her tubes being open or not, and her husband’s semen analysis.’
Daniela: For the woman who has been diagnosed with severe PCOS, what is the type of treatment followed?
Dr. Rebecca Chilvers: If her tubes are open and her husband has an adequate sperm count and motility then I usually start with ovarian stimulation using Femara (also known as letrozole), though Clomid can be used as well, to help her develop a mature egg. Once this mature follicle develops and is verified on ultrasound, I give the patient an injection of hCG, which will trigger ovulation and allow for the timing of intercourse at home or an IUI. Most patients want to have the IUI rather than start with timed intercourse but I allow them to make that decision, since even with a normal semen analysis, IUI is beneficial in helping improve pregnancy rates. If the woman is older or has not conceived with IUI after a few cycles or if her husband’s sperm count or motility are very low, then we usually talk about IVF as the better option. The severity of PCOS can be gauged in different ways, but the treatments are still chosen based on the patient’s age and ovarian reserve (number of eggs she has left), her tubes being open or not, and her husband’s semen analysis. Some women may be resistant to the lower doses of medication and over respond to higher doses. Usually, these patients do better with IVF since there is more room to allow the ovaries to blossom with mature eggs as they will be retrieved and embryos will be made outside of the body that can be placed individually in the uterus and allow for best chances for them to have a healthy singleton pregnancy.
Daniela If I understand well then, if the woman has been diagnosed with PCOS and the partner also has sperm count and motility issues, IVF would be the option to go for?
Dr. Rebecca Chilvers: If mildly low parameters, then the sperm may be sufficient for IUI, but if the total amount of motile sperm in the specimen is less than 20 million, then I recommend IVF with injection of a single sperm into each egg (process is known as ICSI), which has revolutionized male factor infertility. The reason the total motile count is important is that during preparation of the sperm for IUI, about 1/2 of the sperm are lost. You want at least 10 million total motile sperm after wash to be able to say there are good chances for pregnancy with IUI. I have had patients conceive with fewer sperm than this with IUI but this is not often.
Daniela: If you could maybe provide more information on the ICSI process?
Dr. Rebecca Chilvers: ICSI is a technical procedure that is performed after eggs are retrieved in the IVF process. The sperm are selected based on how they are swimming and their shape and are injected by a trained embryologist using a glass needle through the outer layer of the egg so that fertilization rates are greatly improved.
Cysts, follicles, and eggs. What is the difference?
Daniela: Going back to the basics, when speaking about PCOS it seems that many terms are used interchangeably, potentially affecting clarity. In this regard, how would you define the difference between cyst, follicle, and egg?
Dr. Rebecca Chilvers: The ovary is a dynamic organ that is changing throughout the menstrual cycle. It is best for me to start by explaining that a follicle is a sac of fluid that contains an egg. The follicle can be seen on ultrasound and looks like a dark circle as is water density fluid, whereas the egg itself is too small to see on ultrasound. As an egg matures during the menstrual cycle and before ovulation, the follicle will enlarge to 1.8-2 cm in size. That follicle will rupture at the time of ovulation to release the egg into the pelvis for the tube to pick it up to meet the sperm. An ovarian cyst, by contrast, is a sac of fluid that arises in the ovary, usually from a developing follicle, but that is present at the wrong time during the menstrual cycle, is much larger than expected, or is persistent for months. Sometimes cysts can be “simple” and just have fluid in them, similar to a follicle, and other times they can be “complex” and have blood or a solid mass in them. Masses can be benign or malignant. In patients with PCOS, typically the ovary will have many, many follicles in it, most of them located at the outer layers of the ovary, giving the so called “pearl necklace” sign seen in text books. I tell my patients the syndrome should really be called polyfollicular ovarian syndrome, but that would be harder for people to say and understand — though now you do!
‘The follicle can be seen on ultrasound and looks like a dark circle as is water density fluid, whereas the egg itself is too small to see on ultrasound.’
Daniela: What are the distinguishing features between a ‘good cyst’ and a ‘bad cyst’ when diagnosing/monitoring PCOS?
Dr. Rebecca Chilvers: By “good cyst” possibly you are referring to a developing or dominant follicle, the sac of fluid that contains the maturing egg, which would be the result of a good treatment protocol meant to mature 1-3 follicles for eventual ovulation. A “bad cyst” may refer to a follicle that is left over from a preceding menstrual cycle and so prevents us from starting the new cycle. We typically check the ovaries for cysts before starting medications to stimulate the ovaries so that we have new mature follicles and not confusing with the old. Honestly, in my practice I don’t refer to good or bad cysts. We just refer to them as follicles (such as when diagnosing patients with PCOS or monitoring them for treatment response) or as cysts when there is a large and/or persistent follicle that should not be present at that time in the cycle.
Daniela: If a woman is diagnosed with an ovarian cyst, does this mean she has PCOS?
Dr. Rebecca Chilvers: No. The diagnosis requires 2 of 3 features: 1) irregular cycles, 2) clinical symptoms of acne or male pattern hair growth or blood work showing elevated androgens/male hormones such as testosterone, 3) polycystic ovaries on ultrasound. An ovarian cyst is different as described above. It is also notable that patients with and without PCOS develop cysts that usually will come and go since the ovary usually has follicles growing and ovulating each month.
Daniela: What happens when numerous follicles keep growing without approaching maturity? Is medication necessary to get rid of these immature follicles or they go away on their own?
Dr. Rebecca Chilvers: Follicles in patients with PCOS typically only reach an early stage of development. They are advanced enough to see them on ultrasound, but not mature enough to ovulate. Fertility medication is usually required to stimulate them to grow to a mature state, and the goal in my practice is to help 1-3 follicles reach mature size so that there is a greater chance for pregnancy while minimizing risks for multiples (twins, triplets). The follicles that don’t reach maturity will go away on their own by a process called atresia. Once atresia has occurred for that month, a new crop of eggs comes through to have a chance to grow. This process of growth and atresia occurs for each cycle naturally. And during the fertility treatment cycle, we want to capture one that becomes mature for ovulation. Since patients with PCOS usually have a low follicle stimulating hormone (FSH), giving medication that causes elevation in FSH for a period of time is usually sufficient to help achieve the desired mature egg or eggs.
‘Most patients with PCOS have fertility issues due to not ovulating rather than due to declining egg quantity and quality.’
Daniela: What happens to the eggs in arrested follicles?
Dr. Rebecca Chilvers: The eggs in follicles that have started to mature but have stopped growing are thought to undergo atresia as described above. It is thought that the ovaries of patients with PCOS have a larger pool of follicles to be recruited into egg development cycle but that the presence of some hormones keeps them suppressed (AMH) and the absence of other hormones keeps them suppressed (FSH). It is then required to increase stimulation of these follicles to grow using FSH (follicle stimulating hormone), but with the goal to end up with only 1-3 mature follicles for ovulation, if the patient is doing IUI (intrauterine insemination), or a goal of multiple mature follicles if the patient is undergoing IVF (in vitro fertilization).
Fertility Preservation as a PCOS patient
Daniela: Would you suggest fertility preservation via egg banking for someone suffering from PCOS?
Dr. Rebecca Chilvers: Most patients with PCOS have fertility issues due to not ovulating rather than due to declining egg quantity and quality. The decision to bank eggs in patients with PCOS is mainly based on social reasons or less often an unexpected cancer diagnosis for example, since patients with PCOS typically run out of eggs later than average. Just as with patients who do not have PCOS, an individual who is single and knows she is going to delay conception until her mid-30s or so should consider fertility preservation with egg freezing. For any patient desiring to preserve their fertility, the prognosis for egg freezing depends on age and number of eggs. Patients with PCOS are particularly good candidates for egg freezing because they have a lot of eggs.
Daniela: As a final question, if there’s one piece of advice that you would give a woman with PCOS who wishes to become a parent, what would it be?
Dr. Rebecca Chilvers: I always encourage my patients with PCOS that though the diagnosis carries some risks, the benefit is that usually, they have higher than average numbers of eggs and therefore better chances of pregnancy than average for their age. Especially through IVF, patients with PCOS will have a higher number of eggs retrieved and more embryos formed, which can be frozen and later transferred into the uterus, usually individually, when the patient desires to conceive. This translates into higher pregnancy rates, and they usually have surplus embryos stored for when they want to have more children, which preserves their fertility. In addition, the protocols are safer and technology more advanced, giving better chances of conceiving one healthy baby at a time with better pregnancy outcomes for mom and baby.
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