September 2012 eNews
It's PCOS Awareness Month:
What it is and how GIVF can help.
By Sunita Kulshrestha, MD, FACOG
Polycystic Ovary Syndrome (PCOS) is the most common female reproductive endocrine disorder affecting between 5-10% of reproductive aged women. The primary cause of PCOS is thought to be genetics. However, environmental influences, such as weight, exercise and diet can change the severity of the symptoms.
PCOS is a common cause of infertility due to chronic anovulation (lack of release of the egg) or infrequent or irregular ovulation. Women with PCOS typically have periods that happen more than thirty-five days apart or have irregular intervals between periods. Some women don’t even have periods. Lack of ovulation provides fewer opportunities for sperm and egg to meet, which means fewer opportunities to get pregnant. If ovulation is irregular, it can be difficult to determine a woman's fertile window, which makes it hard to determine when it’s time to ‘try’ to get pregnant.
PCOS is diagnosed through the combination of a patient history, physical exam and blood work and is defined as having at least 2 of the following three characteristics:
1) Chronic anovulation
2) Chronic hyperandrogenism (excess male hormone production)
3) PCOS appearing ovaries
Hyperandrogenism is an excess of male hormones (like testosterone). This can contribute to ovulatory dysfunction and can also affect egg quality. It can also contribute to excess hair growth, causing coarse hairs on the face, chest, lower abdomen and back. Hyperandrogenism can also cause acne, oily skin and male pattern thinning or baldness. Some women with PCOS can have laboratory evidence of excess androgens, but they do not have hirsutism or acne. The polycystic appearing ovaries can be seen on a pelvic ultrasound. They are plump and contain multiple small follicles (fluid-filled sacs that contain immature eggs).
Obesity is common in patients who have PCOS. However, weight is not a defining characteristic of PCOS as lean patients also have PCOS. Patients with PCOS can have varying symptoms. One extreme is the patient who is obese, has a few periods a year, and has highly visible and excess facial hair growth and the other extreme is a lean patient who has no acne or hair growth and only has mild menstrual irregularity. No specific test can definitely diagnose PCOS. Your doctor must consider all of your signs and symptoms and then rule out other possible disorders before confirming the diagnosis.
The management of PCOS related infertility begins with diet and exercise in order to achieve an ideal body weight. Medical treatment can restore normal ovulation. Clomiphene Citrate is a commonly used oral medication that is taken for 5 days each month. Its use supports the normal progression and development of the egg followed by ovulation. Clomiphene can also help produce and release more than one egg and because of that, the possibility of a multiple pregnancy does exist. The chance of twins with Clomid is about 7% and the chance of triplets is less than 1%. Most patients do not have side effects from this medication. Those who do may experience mild headaches, mood swings, abdominal bloating, visual effects, hot flashes, and symptoms comparable to those felt in the premenstrual period. Clomiphene citrate restores normal ovulation in approximately 80% of patients with PCOS and its use can be combined either with natural timed sexual activity or with an intrauterine sperm insemination (IUI). Approximately 40% of patients who have PCOS and an ovulatory disturbance deliver babies with the use of Clomid with repeated cycles.
Patients who do not conceive with Clomid can benefit from other treatments, including the use of Metformin or gonadotropins. Metformin is an oral agent that can help improve a patient’s sensitivity to Clomid and can restore spontaneous ovulation. The medication can safely be used through pregnancy. Side effects of Metformin are present in up to 20% of patients and may include gastrointestinal side effects.
The gonadotropins are injectable medications, most commonly the follicle stimulating hormone (FSH). This treatment involves taking a daily injection (smaller than a blood draw needle) for approximately 7-10 days with close monitoring through bloodwork and vaginal ultrasounds. Ovulation induction with FSH is often performed in conjunction with an IUI. Most patients do not have side effects from this medication, but some experience mild abdominal bloating, headaches, mood swings and symptoms comparable to those felt in the premenstrual period. The gonadotropins can lead to a higher risk of multiples since PCOS ovaries respond well to this medication and more eggs are produced and they all have the ability to become fertilized. Because of this, monitoring is essential to minimize the risk of a high order mulitiple pregnancy (triples or more). The multiple pregnancy risk is the greatest concern in patients with PCOS who undergo treatment with FSH. A multiple pregnancy is a more complicated pregnancy for both the mother and the babies and is associated with a greater risk of diabetes in pregnancy, hypertension in pregnancy, need for a C-section and a greater risk of preterm delivery and complications for the baby.
For patients who are unsuccessful in achieving pregnancy with ovulation induction and IUI, or for those who want to minimize the chance of a multiple pregnancy, in-vitro fertilization (IVF) offers great success. IVF has the advantage of producing multiple eggs and embryos but at the same time it can minimize the risk of a multiple pregnancy since one has control over the number of embroys transferred. Patients can choose to transfer a single embryo. In IVF, the medication protocol involves the same gonadotropin injections that are used in the FSH/IUI protocol but at a higher dosage and sometimes for a longer time. The eggs are collected in a procedure in an outpatient office procedure called transvaginal egg retrieval. During the procedure, the patient is asleep and pain-free. The eggs are collected, fertilized in the dish and then transferred back into the uterus. IVF is the procedure of choice, if in addition to PCOS, there is a tubal/pelvic or male factor involved in the cause of the couple's infertility since it can bypass all of these issues. Pregnancy rates with IVF are dependent on a woman’s age and embryo quality, but are about 3-4 times as effective as IUI and can be as high as 60-70% per cycle.
PCOS is also associated with longer term health consequences. Infrequent menstruation at any age can increase the chance of endometrial hyperplasia (thickened lining of the uterus) and endometrial cancer. That’s why it’s important that, regardless of fertility concerns, patients with PCOS have menstrual cycles. Medications such as birth control pills and progesterone can help patients who don’t ovulate have periods. Patients with PCOS are more likely to develop diabetes, even in their 20s and 30s. Metformin is also used to treat glucose intolerance and diabetes. Later in life PCOS patients are also more likely to develop hypertension (high blood pressure), obstructive sleep apnea, elevated cholesterol and triglycerides, and coronary artery disease.
The good news is that treating infertility related to PCOS is highly effective and we can help you. We’d be happy to talk with you more about this and other fertility challenges. Please call us to schedule a consultation at 703.698.7355 or 800.552.4363.
Dr. Sunita Kulshrestha is board-certified in Reproductive Endocrinology and specializes in endocrine causes of fertility such as PCOS.
Here is some additional information about PCOS from our friends at RESOLVE.
September is Also Ovarian Cancer Awareness Month.
Ovarian cancer is one of the many types of cancer women should be aware of and find early for a better chance of survival. The links below offer more information about ovarian cancer. At GIVF, our Fertility Preservation Center for Cancer Patients, is designed specifically to help those undergoing treatments hang onto their chance to have a family in the future.
GIVF Doctors Speak Internationally About Advanced Technologies in Genetics
GIVF was featured internationally this month as Shanghai was the host city for a conference attended by doctors from all over the world to discuss advances in medicine related to infertility. The 39th Session of National Class on Reproductive Endocrinology & Advances in Assisted Reproductive Technology was jointly hosted by the Ob/Gyn Hospital of Fudan University and GIVF’s International Division Shanghai Ji Ai.
Our very own Dr. Harvey Stern spoke on “How Chromosomal Microarray PGD Will Change IVF.” Chromosomal Microarray (often shortened to CMA) is a test that can be done on embryos before implantation to look for abnormalities that would cause significant disease. This type of preimplantation genetic diagnosis (PGD) is a significant improvement over the most commonly used routine tests. At GIVF, we have an extensive genetics program and use these highly advanced technologies for PGD to help our patients, which makes Dr. Stern a great choice to educate peers on this topic.
Dr. Stern spoke on how CMA allows fast and accurate diagnosis of chromosome abnormalities in embryos which allows doctors to choose the embryos with the highest potential to be a healthy baby. For a couple considering implanting just one embryo at a time, CMA is a very effective test.
Veronica Novik, PhD, the Assistant Director for GIVF’s Diagnostic Laboratory, also spoke in Shanghai, but focused on the “Analysis and Significance of Mosaicism Detected by Chromosomal Microarray PGD.” Mosaicism is a condition where cells in the same embryo, pregnancy, or individual can have different genetic makeup. It is caused by an error in cell division. Dr. Novik’s discussion focused on important factors in identifying mosaicism in embryos, including the sample tested and the technology used. She reviewed GIVF’s recent data on designing an algorithm to identify mosaicism in embryos. Using CMA and this information, GIVF’s PGD lab is able to identify mosaicism at a much lower percentage than we were able to previously.
Our genetics team is proud to be on the cutting edge of the latest technology so that we can provide our patients with the best chance to have a healthy family.
The Genetics & IVF Institute (GIVF) regularly publishes an informative newsletter featuring the latest infertility news and developments. The newsletter is sent electronically via email. To subscribe, click here.