Polycystic Ovarian Syndrome (PCOS) is a common cause of female infertility. The condition prevents consistent ovulation – that is the regular release of an egg – and is characterized by small cystic structures within the ovaries. The follicles in polycystic ovaries do not develop and mature well, hence affecting ovulation.
Charles from Dreaming of Baby speaks with Dr. Aimee Eyvazzadeh, a fertility specialist based in San Francisco, California, also known as the ‘Egg Whisperer’. Dr. Aimee speaks about the difference between mild and severe PCOS, treating the condition, the journey to baby as a PCOS patient, and the role your eggs play in all of this.
Charles: Welcome Dr. Aimee! Dr. Aimee will be helping us understand PCOS. Dr, would you be so kind as to tell our readers a little about yourself and your experience in working with PCOS sufferers dreaming of having a baby?
Dr. Aimee: I love helping patients with PCOS. The reason? Well, so many have heard things like, “you have a lot of eggs but they’re all rotten” or “you’ll never have a baby” and that couldn’t be further from the truth. PCOS is a very complex condition that requires testing and interpretation of hormone levels. The hormonal imbalance can be treated and patients with PCOS can get pregnant and can have a baby.
I help PCOS patients get pregnant with fertility pills, IUI, IVF and I have had plenty of patients that have also achieved pregnancy after starting PCOS treatment.
Charles: Understandably the condition varies from one patient to the next; can you walk us through what one may consider mild PCOS to more severe cases of PCOS. What are the main differences in your experience?
Dr. Aimee: Absolutely. A patient with mild PCOS may have 10 menstrual cycles a year, skipping maybe one or two or will have 7-8 cycles a year but the cycles are long, perhaps 40 to 45 days. A patient with severe PCOS to me is someone who isn’t ovulating at all and has what we call “secondary amenorrhea.” This means an absence of periods. A woman with severe PCOS will take progesterone or birth control pills to induce a period.
Women with severe PCOS may also have problems with: temporal balding (aka “male pattern balding), hirsutism (more hair in areas like the chin, lower and upper abdomen and inner thighs) and acne. Women with severe PCOS tend to have a more difficult time responding to fertility pills while women with mild PCOS respond very nicely to fertility pills.
‘The reason why a PCOS patient may want to consider IVF is because of the risk of twins and triplets or more when a PCOS patient takes fertility pills/shots.’
Charles: In terms of treatment what is the most intense form of treatment one may need to become pregnant? (Excluding any male factor infertility issues).
Dr. Aimee: IVF. The reason why a PCOS patient may want to consider IVF is because of the risk of twins and triplets or more when a PCOS patient takes fertility pills/shots.
When a patient ovulates two or more eggs, there is no control over how many embryos end up in the uterus. Take for example Kate Gosselin from the show John and Kate + 8. She has PCOS and she got pregnant from an ovulation induction cycle. So, the benefit of doing IVF with PCOS is controlling the number of embryos transferred and with advances in technology we prefer to transfer one embryo at a time.
Charles: Is IVF generally done once all other options are tried or would a patient showing signs of severe PCOS be referred directly to opting for IVF?
Dr. Aimee: In general, because of the risk for OHSS (ovarian hyperstimulation syndrome), we generally choose to start with fertility pills and start with a low dose. I let my patients with severe PCOS know that there is a 25% chance they may not respond to a course of fertility pills just so they’re not disappointed. I try to keep things really positive and say things like, “you’re so dangerously fertile, and there’s no ovary that we can’t get to listen to us…just depends on how loud we need to talk to it!”. But in general, we start with fertility pills first unless of course: 1. the fallopian tubes are blocked or 2. there is a severe sperm issue or 3. the patient is over a certain age and it would make sense to do IVF instead of treatments with a lower quality.
I’ve certainly had PCOS patients who choose to go right to IVF because they want to preserve their fertility and not have to go through treatment for future children. Most patients though would consider fertility pills as a first line of treatment.
‘Without treatment and guidance from your “PCOS team” of health care providers, women with PCOS will gain weight over time, the lining of the uterus will become thicker and thicker, the hair loss, acne and other symptoms associated with hair can also worsen.’
Charles: Does PCOS get worse over time?
Dr. Aimee: One of the biggest myths about PCOS is: “PCOS is something you treat only when you are trying to get pregnant.” There isn’t anything that could be furthest from the truth when it comes to PCOS, especially severe PCOS. It makes me sad to see women with untreated PCOS coming to me in their mid-30s. Why? Well, it’s because the symptoms get worse over time. Without treatment and guidance from your “PCOS team” of health care providers, women with PCOS will gain weight over time, the lining of the uterus will become thicker and thicker, the hair loss, acne and other symptoms associated with hair can also worsen.
I tell patients with PCOS to, first: Please confirm this Ovary Syndrome, and secondly: Find your PCOS team! The PCOS team includes a nutritionist, endocrinologist, personal trainer, and therapist. PCOS is a lifelong condition that requires lifelong treatment and management.
Charles: I am going to side step for a moment here, specifically because of the worsening over time aspect. Recently fertility preservation has changed status and is no longer considered experimental. For younger PCOS sufferers would you advise fertility preservation?
Dr. Aimee: Yes. I really would. But fertility preservation for a PCOS patient must be done with a doctor that is going to handhold a patient from start to finish. I typically see my patients 5 times during an IVF cycle. For a patient with PCOS, it may be 5-7! The reason for so many visits is because of the high risk for OHSS.
The medication dose has to be chosen carefully and patients have to be followed very very closely to make sure they stay safe throughout the process. If your doctor is scared of your ovaries, they aren’t the right doctor for you. For example, I’ll start patients on a very low dose of medications and see them after only 2 injections to check levels and titrate their doses as needed.
‘If a PCOS patient did fertility preservation earlier they may have a better outcome using their 30-year-old eggs when they’re 38 rather than using their 38-year-old egg when they’re 38.’
Charles: For a PCOS sufferer considering having children later on in life, can you give us a very quick overview of what fertility preservation would entail? Is it different for a PCOS sufferer than it would be for someone without the condition?
Dr. Aimee: You hear this a lot from PCOS patients who go through IVF, “I had a lot of eggs but they weren’t good” and this often times is related to age. So, if a PCOS patient did fertility preservation earlier they may have a better outcome using their 30-year-old eggs when they’re 38 rather than using their 38-year-old egg when they’re 38.
PCOS sufferers choosing to do fertility preservation with me will get the following:
- Diet and nutrition advice and referral to a fertility nutritionist like Judy at www.mind-body-nutrition.com;
- Supplement Guide. I ask them to take supplements like Ovasitol and coq10;
- Prescription medications to also hopefully help improve egg quality and lessen side effects like OHSS: metformin;
- And I always look at everything else: thyroid issues, prolactin levels and testosterone, and aim to get the hormones balanced before we move forward with a fertility preservation procedure.
My approach to any fertility preservation cycle is: I get one chance to do it right so I’m going to make all recommendations up front rather than say, “Oh we should have had you perhaps do this or that first and maybe then we would have had a better cycle.” I also recommend acupuncture to my PCOS patients even the ones going through fertility preservation as well.
Charles: If you could tell us a little more about fertility preservation once the 4 points above are complete and taken into consideration.
Dr. Aimee: Once the fertility preservation cycle is over, I review the egg quality with my patients and tell them if I think they have the number of eggs or embryos cryopreserved for them to meet their family size goals. I also recommend a fertility gene test that looks at genes related to egg quality even before the fertility preservation procedure as well. This helps me understand more about the right protocol for them to use.
Charles: I would like to thank Dr. Aimee for joining us today and providing insight into the condition and treatment. If there was one last thing our readers should hear about PCOS what would it be?
Dr. Aimee: PCOS doesn’t mean you are infertile. PCOS doesn’t mean that you won’t reach your goals of having a baby. You may need a little help from science but do everything you can to get the right medical advice and keep asking questions until you get the help you need.
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